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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: 44] [Impact Index Per Article: 44.0] [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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Caradu C, Ammollo RP, Dari L, Wanhainen A, Van Herzeele I, Bellmunt-Montoya S, Ducasse E, Bérard X. Management of Inflammatory Aortic Aneurysms - A Scoping Review. Eur J Vasc Endovasc Surg 2023; 65:493-502. [PMID: 36623764 DOI: 10.1016/j.ejvs.2023.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 12/20/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Inflammatory abdominal aortic aneurysms (InflAAAs) account for 5 - 10% of aortic aneurysms and are characterised by retroperitoneal fibrosis. Diagnosis is often delayed, and doubts remain about the optimal management strategy. This scoping review describes the current state of knowledge on InflAAAs. METHODS Medline, PubMed, EMBASE, and Scopus were searched for relevant studies that evaluated the diagnosis and treatment of InflAAAs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol was followed. RESULTS Fifty-seven papers were selected (low level of evidence), which included 1 554 patients, who were mostly male and heavy smokers. A triad of chronic abdominal or back pain, weight loss, and elevated inflammatory markers was highly suggestive of the diagnosis but rarely present, and fever was noted only randomly. A mantle sign was seen on computed tomography angiography (CTA) in 73 - 100% of patients. Open surgical repair (OSR) and endovascular aortic aneurysm repair (EVAR) was reported in 1 376 and 178 patients, respectively. OSR was associated with significant iatrogenic bowel (n = 22), urinary tract system (n = 7), venous (n = 30), pancreatic (n = 6), and splenic (n = 5) injuries, while EVAR was associated with lower 30 day mortality (0 - 5% vs. 0 - 32%). One and two year mortality rates were similar between the two treatment modalities (0 - 20% and 0 - 36%, respectively). EVAR was more often associated with post-operative progression of inflammation (17% vs. 0.4%), and a higher frequency of persistent hydronephrosis (> 50%) and limb occlusion (20%). Used in < 10% of patients, corticosteroids led to complete pain relief and a reduction in peri-aortic inflammation within 6 - 18 months. CONCLUSION InflAAAs are characterised by non-specific symptoms, with the mantle sign on CTA being pathognomonic. Corticosteroids may be considered a basic treatment that all patients should receive initially. Low quality data indicate that EVAR (vs. OSR) is associated with fewer intra-operative complications and lower peri-operative mortality but more late fibrosis related adverse events. International multicentre registries are required to gather more insights into this challenging pathology.
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Affiliation(s)
- Caroline Caradu
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Raffaele P Ammollo
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France; Vascular and Endovascular Surgery Unit, Department of Public Health, University Federico II of Naples, Naples, Italy
| | - Loubna Dari
- Department of Vascular Medicine, Bordeaux University Hospital, Bordeaux, France
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Peri-operative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Sergi Bellmunt-Montoya
- Department of Vascular and Endovascular Surgery, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Eric Ducasse
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Bérard
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France.
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Floros N, Papadakis M, Wagenhäuser MU, Duran M, Simon F, Schelzig H, Oberhuber A. Outcomes after Open Surgery for Inflammatory Abdominal Aortic Aneurysm: A 10-Year Single-Center Experience. Ann Vasc Surg 2017; 43:144-150. [PMID: 28478162 DOI: 10.1016/j.avsg.2017.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 01/23/2017] [Accepted: 04/11/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Nikolaos Floros
- Department of Vascular and Endovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany.
| | - Marios Papadakis
- Department of Plastic Surgery, HELIOS Clinic Wuppertal, University Hospital Witten-Herdecke, Wuppertal, Germany
| | - Markus Udo Wagenhäuser
- Department of Vascular and Endovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Mansur Duran
- Department of Vascular and Endovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Florian Simon
- Department of Vascular and Endovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Dusseldorf, Dusseldorf, Germany
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Kakkos SK, Papazoglou KO, Tsolakis IA, Lampropoulos G, Papadoulas SI, Antoniadis PN. Open Versus Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms. Vasc Endovascular Surg 2015; 49:110-8. [DOI: 10.1177/1538574415602780] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Open surgical repair (OSR) of inflammatory abdominal aortic aneurysms (IAAAs) can have significant morbidity. The aim of the present investigation was to compare IAAA outcome after OSR and endovascular aneurysm repair (EVAR) and perform a meta-analysis of the literature. Methods: Twenty-seven patients with an intact IAAA operated on during a 21-year period were included. Results: Nine patients were managed with EVAR and 18 with OSR. In the EVAR group, the number of transfused red blood cell units ( P = .001), procedure duration ( P < .001), and postoperative hospitalization ( P = .004) were significantly reduced compared to OSR. A trend for decreased morbidity with EVAR (11% vs 33% for OSR, P = .36) was observed. On literature review and meta-analysis, morbidity after EVAR was 8.3%, significantly lower compared to OSR (27.4%, P = .047). Mortality for nonruptured IAAAs was 0% after EVAR and 3.6% after OSR ( P = 1.00). Conclusions: Endovascular aneurysm repair of IAAAs is associated with decreased procedure duration, transfusion needs, hospitalization, and morbidity compared to OSR.
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Affiliation(s)
- Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras, Athens, Greece
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Rigberg D, Jimenez JC, Lawrence P, Gelabert H. A combined endovascular and open ''reverse hybrid'' technique for repair of complex juxtarenal inflammatory aortic aneurysms. Vasc Endovascular Surg 2009; 43:494-6. [PMID: 19850595 DOI: 10.1177/1538574409335036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Inflammatory abdominal aortic aneurysms (IAAA) can present significant challenges to surgeons, especially in the juxtarenal location where they may not be amenable to endovascular repair. The dense, inflammatory component of these lesions can encase adjacent structures including the duodenum, ureters, and inferior vena cava putting them at risk for injury during open exposure. We report a novel ''reverse hybrid'' technique using a combined endovascular and open approach for repair of large, juxtarenal IAAA's.
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Affiliation(s)
- David Rigberg
- Division of Vascular Surgery, UCLA, Los Angeles, California, USA
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Ganten MK, Weber TF, von Tengg-Kobligk H, Böckler D, Stiller W, Geisbüsch P, Kauffmann GW, Delorme S, Bock M, Kauczor HU. Motion characterization of aortic wall and intimal flap by ECG-gated CT in patients with chronic B-dissection. Eur J Radiol 2009; 72:146-53. [DOI: 10.1016/j.ejrad.2008.06.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 06/10/2008] [Accepted: 06/25/2008] [Indexed: 01/14/2023]
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Paravastu SCV, Ghosh J, Murray D, Farquharson FG, Serracino-Inglott F, Walker MG. A Systematic Review of Open Versus Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2009; 38:291-7. [PMID: 19541509 DOI: 10.1016/j.ejvs.2009.05.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 05/09/2009] [Indexed: 11/30/2022]
Affiliation(s)
- S C V Paravastu
- Department of Vascular and Endovascular Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.
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van Bommel EFH, van der Veer SJ, Hendriksz TR, Bleumink GS. Persistent chronic peri-aortitis (‘inflammatory aneurysm’) after abdominal aortic aneurysm repair: systematic review of the literature. Vasc Med 2008; 13:293-303. [DOI: 10.1177/1358863x08091147] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract Data on the outcome of aneurysmal chronic peri-aortitis (‘inflammatory aneurysm’) after open surgical aneurysm repair are few and contradictory. To what extent this inflammatory process is reversed after endovascular aneurysm repair (EVAR) is even more unclear. The objective of this review was to study the outcome of peri-aortic fibrosis (PAF) and ureteral obstruction in patients with aneurysmal chronic peri-aortitis treated with open surgery or EVAR. Medical literature was searched for pertinent articles on the outcome of PAF and ureteral obstruction after open surgery or EVAR from 1970 through October 2007. Studies were included if specific follow-up data were available on outcomes of interest. A total of 19 studies were included comprising 478 patients (open surgical, n = 426; EVAR, n = 52). Age, sex and percentage of patients with ureteral obstruction (31% vs 37%) did not differ between groups. Regression of PAF occurred more frequently after open surgery compared to EVAR (86% vs 60%; p < 0.0001). Complete regression of PAF was more frequent after open surgery compared to EVAR (52% vs 14%; p < 0.0001). After excluding patients in whom concurrent ureterolysis was performed, the frequency of persistent ureteral obstruction remained lower in patients treated surgically compared to patients treated with EVAR, albeit not statistically significant (32% vs 56%; p = 0.09). In conclusion, although open surgery is superior to EVAR in achieving regression of chronic peri-aortitis, the frequency of persistent PAF and/or ureteral obstruction is not negligible. Additional medical and/or urological treatment should be considered in selected cases of aneurysmal chronic peri-aortitis.
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Affiliation(s)
- EFH van Bommel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - SJ van der Veer
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - TR Hendriksz
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - GS Bleumink
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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