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Chen J, Hu L, Liu Z. Medical treatments for abdominal aortic aneurysm: an overview of clinical trials. Expert Opin Investig Drugs 2024:1-14. [PMID: 38978286 DOI: 10.1080/13543784.2024.2377747] [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: 01/29/2024] [Accepted: 07/04/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION Abdominal aortic aneurysm is a progressive, segmental, abdominal aortic dilation associated with a high mortality rate. Abdominal aortic aneurysms with diameters larger than 55 mm are associated with a high risk of rupture, and the most effective treatment options are surgical repair. Close observation and lifestyle adjustments are recommended for smaller abdominal aortic aneurysms with lower rupture risk. The development of medical therapies that limit or prevent the progression, expansion, and eventual rupture of abdominal aortic aneurysms remains an unmet clinical need. AREAS COVERED This review provides an overview of completed and ongoing clinical trials examining the efficacies of various drug classes, including antibiotics, antihypertensive drugs, hypolipidemic drugs, hypoglycemic drugs, and other potential therapies for abdominal aortic aneurysms. A search of PubMed, Web of Science, Clinical Trials, and another six clinical trial registries was conducted in January 2024. EXPERT OPINION None of the drugs have enough evidence to indicate that they can effectively inhibit the dilation of abdominal aortic aneurysm. More clinical trial data is required to support the efficacy of propranolol. Future research should also explore different drug delivery mechanisms, such as nanoparticles, to elevate drug concentration at the aneurysm wall.
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Affiliation(s)
- Jinyi Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lanting Hu
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Zhenjie Liu
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 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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Prendes CF, Gouveia E Melo R, Caldeira D, D'Oria M, Tsilimparis N, Koelemay M, Van Herzeele I, Wanhainen A. Editor's Choice - Systematic Review and Meta-Analysis of Contemporary Abdominal Aortic Aneurysm Growth Rates. Eur J Vasc Endovasc Surg 2024; 67:132-145. [PMID: 37777049 DOI: 10.1016/j.ejvs.2023.09.039] [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: 11/15/2022] [Revised: 08/17/2023] [Accepted: 09/21/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE To evaluate the contemporary growth rate of small abdominal aortic aneurysms (AAAs) in view of recent epidemiological changes, such as decreasing smoking rates and establishment of population screening programmes. DATA SOURCES MEDLINE, CENTRAL, PsycINFO, Web of Science Core Collection, and OpenGrey databases. REVIEW METHODS Systematic review following the PRISMA guidelines. In October 2021, databases were queried for studies reporting on AAA growth rates published from 2015 onwards. The primary outcome was contemporary AAA growth rates in mm/year. Data were pooled in a random effects model meta-analysis, and heterogeneity was assessed through the I2 statistic. GRADE assessment of the findings was performed. The protocol was published in PROSPERO (CRD42022297404). RESULTS Of 8 717 titles identified, 43 studies and 28 277 patients were included: 1 241 patients from randomised controlled trials (RCTs), 23 941 from clinical observational studies, and 3 095 from radiological or translational research studies. The mean AAA growth rate was 2.38 mm/year (95% CI 2.16 - 2.60 mm/year; GRADE = low), with meta-regression analysis adjusted for baseline diameter showing an increase of 0.08 mm/year (95% CI 0.024 - 0.137 mm/year; p = .005) for each millimetre of increased baseline diameter. When analysed by study type, the growth rate estimated from RCTs was 1.88 mm/year (95% CI 1.69 - 2.06 mm/year; GRADE = high), while it was 2.31 mm/year (95% CI 1.95 - 2.67 mm/year; GRADE = moderate) from clinical observational studies, and 2.85 mm/year (95% CI 2.44 - 3.26 mm/year; GRADE = low) from translational and radiology based studies (p < .001). Heterogeneity was high, and small study publication bias was present (p = .003), with 27 studies presenting a moderate to high risk of bias. The estimated growth rate from low risk studies was 2.09 mm/year (95% CI 1.87 - 2.32; GRADE = high). CONCLUSION This study estimated a contemporaneous AAA growth rate of 2.38 mm/year, being unable to demonstrate any clinically meaningful AAA growth rate reduction concomitant with changed AAA epidemiology. This suggests that the RESCAN recommendations on small AAA surveillance are still valid. However, sub-analysis results from RCTs and high quality study data indicate potential lower AAA growth rates of 1.88 - 2.09 mm/year, findings that should be validated in a high quality prospective registry.
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Affiliation(s)
- Carlota F Prendes
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany.
| | - Ryan Gouveia E Melo
- Vascular Surgery Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Faculdade de Medicina da Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Daniel Caldeira
- Cardiology Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Centro de Estudos de Medicina Baseada na Evidência (CEMB), Faculdade de Medicina da Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, Munich, Germany
| | - Mark Koelemay
- Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala, Sweden; Department of Peri-operative and Surgical Sciences, Section of Surgery, Umeå University, Umeå, Sweden
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Yodsanit N, Shirasu T, Huang Y, Yin L, Islam ZH, Gregg AC, Riccio AM, Tang R, Kent EW, Wang Y, Xie R, Zhao Y, Ye M, Zhu J, Huang Y, Hoyt N, Zhang M, Hossack JA, Salmon M, Kent KC, Guo LW, Gong S, Wang B. Targeted PERK inhibition with biomimetic nanoclusters confers preventative and interventional benefits to elastase-induced abdominal aortic aneurysms. Bioact Mater 2023; 26:52-63. [PMID: 36875050 PMCID: PMC9975632 DOI: 10.1016/j.bioactmat.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 02/25/2023] Open
Abstract
Abdominal aortic aneurysm (AAA) is a progressive aortic dilatation, causing ∼80% mortality upon rupture. Currently, there is no approved drug therapy for AAA. Surgical repairs are invasive and risky and thus not recommended to patients with small AAAs which, however, account for ∼90% of the newly diagnosed cases. It is therefore a compelling unmet clinical need to discover effective non-invasive strategies to prevent or slow down AAA progression. We contend that the first AAA drug therapy will only arise through discoveries of both effective drug targets and innovative delivery methods. There is substantial evidence that degenerative smooth muscle cells (SMCs) orchestrate AAA pathogenesis and progression. In this study, we made an exciting finding that PERK, the endoplasmic reticulum (ER) stress Protein Kinase R-like ER Kinase, is a potent driver of SMC degeneration and hence a potential therapeutic target. Indeed, local knockdown of PERK in elastase-challenged aorta significantly attenuated AAA lesions in vivo. In parallel, we also conceived a biomimetic nanocluster (NC) design uniquely tailored to AAA-targeting drug delivery. This NC demonstrated excellent AAA homing via a platelet-derived biomembrane coating; and when loaded with a selective PERK inhibitor (PERKi, GSK2656157), the NC therapy conferred remarkable benefits in both preventing aneurysm development and halting the progression of pre-existing aneurysmal lesions in two distinct rodent models of AAA. In summary, our current study not only establishes a new intervention target for mitigating SMC degeneration and aneurysmal pathogenesis, but also provides a powerful tool to facilitate the development of effective drug therapy of AAA.
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Affiliation(s)
- Nisakorn Yodsanit
- Department of Biomedical Engineering, Wisconsin Institute for Discovery, University of Wisconsin-Madison, Madison, WI, 53715, USA
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI, 53715, USA
| | - Takuro Shirasu
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | - Yitao Huang
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
- The Biomedical Sciences Graduate Program (BIMS), School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | - Li Yin
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | - Zain Husain Islam
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | | | - Alessandra Marie Riccio
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | - Runze Tang
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | - Eric William Kent
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | - Yuyuan Wang
- Department of Biomedical Engineering, Wisconsin Institute for Discovery, University of Wisconsin-Madison, Madison, WI, 53715, USA
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI, 53715, USA
| | - Ruosen Xie
- Department of Biomedical Engineering, Wisconsin Institute for Discovery, University of Wisconsin-Madison, Madison, WI, 53715, USA
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI, 53715, USA
| | - Yi Zhao
- Department of Biomedical Engineering, Wisconsin Institute for Discovery, University of Wisconsin-Madison, Madison, WI, 53715, USA
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI, 53715, USA
| | - Mingzhou Ye
- Department of Biomedical Engineering, Wisconsin Institute for Discovery, University of Wisconsin-Madison, Madison, WI, 53715, USA
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI, 53715, USA
| | - Jingcheng Zhu
- Department of Biomedical Engineering, Wisconsin Institute for Discovery, University of Wisconsin-Madison, Madison, WI, 53715, USA
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI, 53715, USA
| | - Yi Huang
- Department of Biomedical Engineering, School of Engineering, University of Virginia, Charlottesville, VA, 22908, USA
| | - Nicholas Hoyt
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
- School of Medicine and Health Sciences, George Washington University, Washington, DC, 20052, USA
| | - Mengxue Zhang
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | - John A. Hossack
- Department of Biomedical Engineering, School of Engineering, University of Virginia, Charlottesville, VA, 22908, USA
| | - Morgan Salmon
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - K. Craig Kent
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | - Lian-Wang Guo
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
| | - Shaoqin Gong
- Department of Biomedical Engineering, Wisconsin Institute for Discovery, University of Wisconsin-Madison, Madison, WI, 53715, USA
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI, 53715, USA
| | - Bowen Wang
- Department of Surgery, School of Medicine, University of Virginia, Charlottesville, VA, 22908, USA
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Development of pharmacotherapies for abdominal aortic aneurysms. Biomed Pharmacother 2022; 153:113340. [PMID: 35780618 PMCID: PMC9514980 DOI: 10.1016/j.biopha.2022.113340] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/13/2022] [Accepted: 06/24/2022] [Indexed: 11/23/2022] Open
Abstract
The cardiovascular field is still searching for a treatment for abdominal aortic aneurysms (AAA). This inflammatory disease often goes undiagnosed until a late stage and associated rupture has a high mortality rate. No pharmacological treatment options are available. Three hallmark factors of AAA pathology include inflammation, extracellular matrix remodeling, and vascular smooth muscle dysfunction. Here we discuss drugs for AAA treatment that have been studied in clinical trials by examining the drug targets and data present for each drug's ability to regulate the aforementioned three hallmark pathways in AAA progression. Historically, drugs that were examined in interventional clinical trials for treatment of AAA were repurposed therapeutics. Novel treatments (biologics, small-molecule compounds etc.) have not been able to reach the clinic, stalling out in pre-clinical studies. Here we discuss the backgrounds of previous investigational drugs in hopes of better informing future development of potential therapeutics. Overall, the highlighted themes discussed here stress the importance of both centralized anti-inflammatory drug targets and rigor of translatability. Exceedingly few murine studies have examined an intervention-based drug treatment in halting further growth of an established AAA despite interventional treatment being the therapeutic approach taken to treat AAA in a clinical setting. Additionally, data suggest that a potentially successful drug target may be a central inflammatory biomarker. Specifically, one that can effectively modulate all three hallmark factors of AAA formation, not just inflammation. It is suggested that inhibiting PGE2 formation with an mPGES-1 inhibitor is a leading drug target for AAA treatment to this end.
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Thomas Manapurathe D, Moxon JV, Krishna SM, Quigley F, Bourke M, Bourke B, Jones RE, Golledge J. Cohort Study Examining the Association of Optimal Blood Pressure Control at Entry With Infrarenal Abdominal Aortic Aneurysm Growth. Front Cardiovasc Med 2022; 9:868889. [PMID: 35592396 PMCID: PMC9110652 DOI: 10.3389/fcvm.2022.868889] [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: 02/03/2022] [Accepted: 03/24/2022] [Indexed: 12/04/2022] Open
Abstract
Background and Aim The benefit of controlling cardiovascular risk factors in slowing the progression of small abdominal aortic aneurysm (AAA) is controversial. This study investigated the association of optimal blood pressure control at entry with the growth of small AAA. Methods and Results A total of 1,293 patients with initial AAA diameter <50 mm were followed by a median 5 (inter-quartile range, IQR, 3–7) ultrasound scans for a median of 3.6 years (IQR 1.8, 5.3). Optimal blood pressure control was defined as blood pressure ≤140/90 mmHg at recruitment. The association of optimal blood pressure control at entry with AAA growth was assessed using linear mixed effects models adjusted for established risk factors of AAA growth and factors which were unequally distributed among the blood pressure groups. Optimal blood pressure control at entry was not significantly associated with AAA growth. In the risk factor adjusted model the mean difference in AAA growth between blood pressure groups was 0.04 mm/year (95% CI −0.20, 0.13; p = 0.65). The results were similar in sensitivity analyses excluding outliers or focused on systolic or diastolic blood pressure alone. Conclusions This observational study suggests that optimal blood pressure control at entry is not associated with slower AAA growth.
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Affiliation(s)
- Diana Thomas Manapurathe
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Joseph Vaughan Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia
| | - Smriti Murali Krishna
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia
| | | | - Michael Bourke
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Gosford Vascular Services, Gosford, NSW, Australia
| | - Bernard Bourke
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Gosford Vascular Services, Gosford, NSW, Australia
| | - Rhondda E. Jones
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, QLD, Australia
- *Correspondence: Jonathan Golledge
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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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Su Z, Guo J, Gu Y. Pharmacotherapy in Clinical Trials for Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2022; 28:10760296221120423. [PMID: 36083182 PMCID: PMC9465599 DOI: 10.1177/10760296221120423] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE There is no medical treatment proven to limit abdominal aortic aneurysm (AAA) progression. This systematic review aimed to summarise available trial evidence on the efficacy of pharmacotherapy in limiting AAA growth and AAA-related events. METHODS A systematic literature search was performed to examine the efficacy of pharmacotherapy in reducing AAA growth and AAA-related events. Pubmed, Embase (Excerpta Medica Database), and the Cochrane library were searched from March, 1999 to March 29, 2022. AAA growth (mm/year) in the intervention and control groups was expressed as mean and standard deviation (SD). The results of AAA growth were expressed as mean difference (MD) and its 95% confidence interval (95% CI). Odds ratios (ORs) were calculated for the AAA-related events.Heterogeneity was quantified using the I2 statistic. Forest plots were created to show the pooled results of each outcome. OUTCOMES A total of 1373 articles were found in different databases according to the search strategy, and 10 articles were identified by hand searching. A total of 26 articles were included in our systematic review after the screening. For the studies of metformin, the meta-analysis demonstrated that metformin use was associated with a lower AAA growth rate (MD: -0.81 mm/y, 95% CI: -1.19 to -0.42, P < 0.0001, I2 = 87%), Metformin use also was related to the lower rates of AAA-related events (OR: 0.53, 95% CI: 0.36 to 0.76, P = 0.0007, I2 = 60%). The hypotensive drugs of the studies mainly included angiotensin-converting enzyme inhibitors (ACEI), angiotensin II type 1 receptor blockers (ARB), and propranolol. The overall meta-analysis of blood pressure-lowering drugs reported no significant effect in limiting the AAA growth (MD: 0.31mm/year, 95%CI: -0.03 to 0.65, P = 0.07, I2 = 66%) and AAA-related events (OR: 1.33, 95%CI: 0.76 to 2.32, P = 0.32, I2 = 98%), In the subgroup analysis of the hypotensive drugs, the ACEI/ARB and propranolol also showed no significant in reducing the AAA growth and AAA-related events. The meta-analysis of the antibiotics demonstrated that the antibiotics were not associated with a lower AAA growth rate (MD: -0.27 mm/y, 95% CI: -0.88 to 0.34, P = 0.39, I2 = 77%) and AAA-related events (OR: 0.94, 95%CI: 0.65 to 1.35, P = 0.72, I2 = 0%). The results of statins also showed no significant effect in limiting AAA growth (MD: -1.11mm/year, 95%CI: -2.38 to 0.16, P = 0.09, I2 = 96%) and AAA-related events (OR: 0.53, 95%CI: 0.26 to 1.06, P = 0.07, I2 = 92%). CONCLUSION In conclusion, effective pharmacotherapy for AAA was still lacking. Although the meta-analysis showed that metformin use was associated with lower AAA growth and AAA-related events, all of the included studies about metformin were cohort studies or case-control studies. More randomized controlled trials (RCTs) are needed for further verification.
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Affiliation(s)
- Zhixiang Su
- Vascular Surgery Department, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianming Guo
- Vascular Surgery Department, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongquan Gu
- Vascular Surgery Department, 71044Xuanwu Hospital, Capital Medical University, Beijing, China
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Xu B, Li G, Guo J, Ikezoe T, Kasirajan K, Zhao S, Dalman RL. Angiotensin-converting enzyme 2, coronavirus disease 2019, and abdominal aortic aneurysms. J Vasc Surg 2021; 74:1740-1751. [PMID: 33600934 PMCID: PMC7944865 DOI: 10.1016/j.jvs.2021.01.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/08/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the etiologic agent of the current, world-wide coronavirus disease 2019 (COVID-19) pandemic. Angiotensin-converting enzyme 2 (ACE2) is the SARS-CoV-2 host entry receptor for cellular inoculation and target organ injury. We reviewed ACE2 expression and the role of ACE2-angiotensin 1-7-Mas receptor axis activity in abdominal aortic aneurysm (AAA) pathogenesis to identify potential COVID-19 influences on AAA disease pathogenesis. METHODS A comprehensive literature search was performed on PubMed, National Library of Medicine. Key words included COVID-19, SARS-CoV-2, AAA, ACE2, ACE or angiotensin II type 1 (AT1) receptor inhibitor, angiotensin 1-7, Mas receptor, age, gender, respiratory diseases, diabetes, and autoimmune diseases. Key publications on the epidemiology and pathogenesis of COVID-19 and AAAs were identified and reviewed. RESULTS All vascular structural cells, including endothelial and smooth muscle cells, fibroblasts, and pericytes express ACE2. Cigarette smoking, diabetes, chronic obstructive pulmonary disease, lupus, certain types of malignancies, and viral infection promote ACE2 expression and activity, with the magnitude of response varying by sex and age. Genetic deficiency of AT1 receptor, or pharmacologic ACE or AT1 inhibition also increases ACE2 and its catalytic product angiotensin 1-7. Genetic ablation or pharmacologic inhibition of ACE2 or Mas receptor augments, whereas ACE2 activation or angiotensin 1-7 treatment attenuates, progression of experimental AAAs. The potential influences of SARS-CoV-2 on AAA pathogenesis include augmented ACE-angiotensin II-AT1 receptor activity resulting from decreased reciprocal ACE2-angiotensin 1-7-Mas activation; increased production of proaneurysmal mediators stimulated by viral spike proteins in ACE2-negative myeloid cells or by ACE2-expressing vascular structural cells; augmented local or systemic cross-talk between viral targeted nonvascular, nonleukocytic ACE2-expressing cells via ligand recognition of their cognate leukocyte receptors; and hypoxemia and increased systemic inflammatory tone experienced during severe COVID-19 illness. CONCLUSIONS COVID-19 may theoretically influence AAA disease through multiple SARS-CoV-2-induced mechanisms. Further investigation and clinical follow-up will be necessary to determine whether and to what extent the COVID-19 pandemic will influence the prevalence, progression, and lethality of AAA disease in the coming decade.
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Affiliation(s)
- Baohui Xu
- Department of Surgery, Stanford University School of Medicine, Stanford, Calif.
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Sun P, Zhang L, Gu Y, Wei S, Wang Z, Li M, Wang W, Wang Z, Bai H. Immune checkpoint programmed death-1 mediates abdominal aortic aneurysm and pseudoaneurysm progression. Biomed Pharmacother 2021; 142:111955. [PMID: 34339918 DOI: 10.1016/j.biopha.2021.111955] [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: 03/11/2021] [Revised: 07/18/2021] [Accepted: 07/20/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE The causes and pathogenetic mechanisms underlying abdominal aortic aneurysms (AAAs) and pseudoaneurysms are not fully understood. We hypothesized that inhibiting programmed death-1 (PD-1) can decrease AAA and pseudoaneurysm formation in mouse and rat models. METHODS Human AAA samples were examined in conjunction with an adventitial calcium chloride (CaCl2) application mouse model and an aortic patch angioplasty rat model. Single-dose PD-1 antibody (4 mg/kg) or BMS-1 (PD-1 inhibitor-1) (1 mg/kg) was administered by intraperitoneal (IP) or intraluminal injection. In the intramural injection group, PD-1 antibody was injected after CaCl2 incubation. The rats were divided into three groups: (1) the control group was only decellularized without other special treatment, (2) the PD-1 antibody-coated patch group, and (3) the BMS-1 coated patch group. Patches implanted in the rat abdominal aorta were harvested on day 14 after implantation and analyzed. RESULTS Immunohistochemical analysis showed PD-1-positive cells, PD-1 and CD3, PD-1 and CD68, and PD-1 and α-actin co-expressed in the human AAA samples. Intraperitoneal (IP) injection or intraluminal injection of PD-1antibody/BMS-1 significantly inhibited AAA progression. PD-1 antibody and BMS-1 were each successfully conjugated to decellularized rat thoracic artery patches, respectively, by hyaluronic acid. Patches coated with either humanized PD-1 antibody or BMS-1 can also inhibit pseudoaneurysm progression and inflammatory cell infiltration. CONCLUSION PD-1 pathway inhibition may be a promising therapeutic strategy for inhibiting AAA and pseudoaneurysm progression.
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MESH Headings
- Aneurysm, False/drug therapy
- Aneurysm, False/metabolism
- Aneurysm, False/pathology
- Angioplasty/methods
- Animals
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Aortic Aneurysm, Abdominal/drug therapy
- Aortic Aneurysm, Abdominal/metabolism
- Aortic Aneurysm, Abdominal/pathology
- B7-H1 Antigen/antagonists & inhibitors
- B7-H1 Antigen/metabolism
- Calcium Chloride/toxicity
- Coated Materials, Biocompatible/pharmacology
- Coated Materials, Biocompatible/therapeutic use
- Disease Models, Animal
- Disease Progression
- Humans
- Immune Checkpoint Inhibitors/pharmacology
- Immune Checkpoint Inhibitors/therapeutic use
- Injections, Intraperitoneal
- Lymphocytes/immunology
- Macrophages/immunology
- Male
- Mice
- Programmed Cell Death 1 Receptor/antagonists & inhibitors
- Programmed Cell Death 1 Receptor/immunology
- Programmed Cell Death 1 Receptor/metabolism
- Rats, Sprague-Dawley
- Rats
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Affiliation(s)
- Peng Sun
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, 450052 Henan, China
| | - Liwei Zhang
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, 450052 Henan, China
| | - Yulei Gu
- Emergency Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, 450052 Henan, China
| | - Shunbo Wei
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, 450052 Henan, China
| | - Zhiwei Wang
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, 450052 Henan, China
| | - Mingxing Li
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, 450052 Henan, China
| | - Wang Wang
- Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, 450002 Henan, China; Department of Physiology, Medical School of Zhengzhou University, 450002 Henan, China
| | - Zhiju Wang
- Department of Physiology, Medical School of Zhengzhou University, 450002 Henan, China
| | - Hualong Bai
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, 450052 Henan, China; Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, 450002 Henan, China.
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11
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Weininger G, Chan SM, Zafar M, Ziganshin BA, Elefteriades JA. Risk reduction and pharmacological strategies to prevent progression of aortic aneurysms. Expert Rev Cardiovasc Ther 2021; 19:619-631. [PMID: 34102944 DOI: 10.1080/14779072.2021.1940958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION While size thresholds exist to determine when aortic aneurysms warrant surgical intervention, there is no consensus on how best to treat this disease before aneurysms reach the threshold for intervention. Since a landmark study in 1994 first suggested ß-blockers may be useful in preventing aortic aneurysm growth, there has been a surge in research investigating different pharmacologic therapies for aortic aneurysms - with very mixed results. AREAS COVERED We have reviewed the existing literature on medical therapies used for thoracic and abdominal aortic aneurysms in humans. These include ß-blockers, angiotensin II receptor blockers, and angiotensin-converting enzyme inhibitors as well as miscellaneous drugs such as tetracyclines, macrolides, statins, and anti-platelet medications. EXPERT OPINION While multiple classes of drugs have been explored for risk reduction in aneurysm disease, with few exceptions results have been disappointing with an abundance of contradictory findings. The vast majority of studies have been done in patients with abdominal aortic aneurysms or thoracic aortic aneurysm patients with Marfan Syndrome. There exists a striking gap in the literature when it comes to pharmacologic management of non-Marfan Syndrome patients with thoracic aortic aneurysms. Given the differences in pathogenesis, this is an important future direction for aortic aneurysm research.
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Affiliation(s)
- Gabe Weininger
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Shin Mei Chan
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Mohammad Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
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12
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Bai H, Sun P, Wei S, Xie B, Li M, Xu Y, Wang W, Liu Y, Zhang L, Wu H, Wang Z, Xing Y, Wang Z, Li J. A novel intramural TGF β 1 hydrogel delivery method to decrease murine abdominal aortic aneurysm and rat aortic pseudoaneurysm formation and progression. Biomed Pharmacother 2021; 137:111296. [PMID: 33545663 DOI: 10.1016/j.biopha.2021.111296] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Aneurysms are generally the result of dilation of all 3 layers of the vessel wall, and pseudoaneurysms are the result of localized extravasation of blood that is contained by surrounding tissue. Since there is still no recommended protocol to decrease aneurysm formation and progression, we hypothesised that intramural delivery of TGF β1 hydrogel can decrease aneurysm and pseudoaneurysm formation and progression. MATERIALS Male C57BL/6 J mice (12-14 wk), SD rats (200 g) and pig abdominal aortas were used, and hydrogels were fabricated by the interaction of sodium alginate (SA), hyaluronic acid (HA) and CaCO3. METHODS A CaCl2 adventitial incubation model in mice and a decellularized human great saphenous vein patch angioplasty model in rats were used. TGF β1 hydrogel was intramurally delivered after CaCl2 incubation in mice; at day 7, the abdomen in some mice was reopened, and TGF β1 hydrogel was injected intramurally into the aorta. In rats, TGF β1 hydrogel was delivered intramurally after patch angioplasty completion. Tissues were harvested at day 14 and analysed by histology and immunohistochemistry staining. The pig aorta was also intramurally injected with hydrogel. RESULTS In mice, rhodamine hydrogel was still found between the medium and adventitia at day 14. In the mouse aneurysm model, there was a thicker wall and smaller amount of elastin breaks in the TGF β1 hydrogel-delivered groups both at day 0 and day 7 after CaCl2 incubation, and there were larger numbers of p-smad2- and TAK1-positive cells in the TGF β1 hydrogel-injected groups. In the rat decellularized human saphenous vein patch pseudoaneurysm model, there was a higher incidence of pseudoaneurysm formation when the patch was decellularized using 3% SDS, and delivery of TGF β1 hydrogel could effectively decrease the formation of pseudoaneurysm formation and increase p-smad2 and TAK1 expression. In pig aortas, hydrogels can be delivered between the medium and adventitia easily and successfully. CONCLUSIONS Intramural delivery of TGF β1 hydrogel can effectively decease aneurysm and pseudoaneurysm formation and progression in both mice and rats, and pig aortas can also be successfully intramurally injected with hydrogel. This technique may be a promising drug delivery method and therapeutic choice to decrease aneurysm and pseudoaneurysm formation and progression in the clinic.
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MESH Headings
- Aneurysm, False/metabolism
- Aneurysm, False/pathology
- Aneurysm, False/prevention & control
- Animals
- Aorta, Abdominal/drug effects
- Aorta, Abdominal/metabolism
- Aorta, Abdominal/pathology
- Aortic Aneurysm, Abdominal/metabolism
- Aortic Aneurysm, Abdominal/pathology
- Aortic Aneurysm, Abdominal/prevention & control
- Delayed-Action Preparations
- Dilatation, Pathologic
- Disease Models, Animal
- Disease Progression
- Drug Carriers
- Drug Compounding
- Hydrogels
- MAP Kinase Kinase Kinases/metabolism
- Male
- Mice, Inbred C57BL
- Phosphorylation
- Rats, Sprague-Dawley
- Smad2 Protein/metabolism
- Sus scrofa
- Transforming Growth Factor beta1/administration & dosage
- Mice
- Rats
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Affiliation(s)
- Hualong Bai
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China; Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Henan, China.
| | - Peng Sun
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Shunbo Wei
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Boao Xie
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Mingxing Li
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yanhua Xu
- Department of Internal Medicine, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Wang Wang
- Department of Physiology, Medical School of Zhengzhou University, Henan, China; Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Henan, China
| | - Yuanfeng Liu
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Liwei Zhang
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Haoliang Wu
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Zhiju Wang
- Department of Physiology, Medical School of Zhengzhou University, Henan, China; Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Henan, China
| | - Ying Xing
- Department of Physiology, Medical School of Zhengzhou University, Henan, China; Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Henan, China
| | - Zhiwei Wang
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Henan, China.
| | - Jing'an Li
- School of Material Science and Engineering & Henan Key Laboratory of Advanced Magnesium Alloy & Key Laboratory of Materials Processing and Mould Technology (Ministry of Education), Zhengzhou University, Henan, China.
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13
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Turowicz A, Kobecki J, Laskowska A, Wojciechowski J, Świątkowski F, Chabowski M. Association of Metformin and Abdominal Aortic Aneurysm Repair Outcomes. Ann Vasc Surg 2021; 75:390-396. [PMID: 33826959 DOI: 10.1016/j.avsg.2021.02.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/14/2021] [Accepted: 02/22/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Metformin is a commonly used drug in diabetes mellitus treatment. Recently it has been suggested that the use of metformin on diabetes mellitus patients may lower the prevalence and slow the progression of AAA (abdominal aortic aneurysm) as well as the risk of rupture related mortality. The aim of this studywas to investigate the impact of metformin treatment on the risk of AAA repair related mortality and surgical complications. METHODS In this retrospective study, the clinical data of 306 patients, including 77 patients with diabetes mellitus, who underwent abdominal aortic aneurysm repair has been analyzed. Treatment outcomes have been investigated. The diabetes and metformin prescription status has been obtained from the medical history. Patients were divided into three groups: diabetes-free individuals, diabetics treated with metformin and diabetics treated with other glucose lowering drugs. The association between metformin treatment and AAA diameter, surgical complications and mortality were assessed using chi-square independence test and odds ratio analysis. In order to assess which factors are influencing AAA repair related complications and mortality a multi-variables analysis has been performed. RESULTS A significant protective effect of metformin treatment towards AAA repair related mortality (P = 0.019) and complications (P = 0.032) among patients suffering from diabetes mellitus was revealed. These findings were statistically insignificant when considering all groups of patients (diabetes-free individuals, diabetics treated with metformin and diabetics treated with other glucose lowering drugs). CONCLUSION Metformin may lower the risk of AAA repair related mortality and surgical complications among patients with diabetes.
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Affiliation(s)
- Agnieszka Turowicz
- Dept of Vascular, General and Transplantation Surgery, Faculty of Medicine, Wroclaw Medical University, Wrocław, Poland; Dept of Surgery, 4(th) Military Teaching Hospital, Wroclaw, Poland.
| | - Jakub Kobecki
- Dept of Surgery, 4(th) Military Teaching Hospital, Wroclaw, Poland; Division of Oncology and Palliative Care, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | | | - Jan Wojciechowski
- Dept of Surgery, 4(th) Military Teaching Hospital, Wroclaw, Poland; Division of Oncology and Palliative Care, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | | | - Mariusz Chabowski
- Dept of Surgery, 4(th) Military Teaching Hospital, Wroclaw, Poland; Division of Oncology and Palliative Care, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
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14
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Maxwell DW, Kenney L, Sarmiento JM, Rajani RR. Aortic Aneurysm Natural Progression is Not Influenced by Concomitant Malignancy and Chemotherapy. Ann Vasc Surg 2020; 71:29-39. [PMID: 32927035 DOI: 10.1016/j.avsg.2020.08.137] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Aortic aneurysms occur concomitantly with malignancy in approximately 1.0-17.0% of patients. There is little published information regarding the effects of subsequent oncological therapies on aortic aneurysm growth. The aim of this study was to determine the effects of chemoradiation therapies on the natural progression of small abdominal aortic aneurysm (AAA), thoracic aortic aneurysm, and thoracoabdominal aortic aneurysm. METHODS Patients with aortic aneurysms with and without malignancy between 2005 and 2017 were identified within institutional databases using Current Procedural Terminology and International Classification of Disease codes. Inclusion criteria included complete chemotherapy documentation, a minimum of 3 multiplanar axial/coronal imaging or ultrasonography before, during, and after receiving therapy or 2 studies for patients without malignancy. Propensity matching, Cox and linear regression, and Kaplan-Meier survival analyses were performed. RESULTS A total of 159 (172 aneurysms) patients with malignancy and 127 (149 aneurysms) patients without malignancy were included. Average patient demographics were 74.4 ± 9.8-years-old, Caucasian (66.8%), male (70.3%), with hypertension (71.1%), current smoking (24.5%), coronary atherosclerotic disease (26.2%), and AAA (71.0%). The most common malignancy was lung cancer (48.4%) with most chemotherapy regimens including a platinum-based alkylating agent and concurrent antimetabolite (56.0%). The overall median follow-up time was 28.2 (range 3.1-174.4) months. Aortic aneurysms in patients without malignancy grew to larger sizes (4.43 ± 0.96 vs. 4.14 ± 1.00, P = 0.008) with similar median growth rates (0.12 vs. 0.12 cm/year, P = 0.090), had more atypical morphologic features (14.1% vs. 0.6%, P < 0.001), more frequently underwent repair (22.1% vs. 8.7%, P = 0.001), and more frequently required emergency repair for rupture (5.4% vs. 0.0%, P = 0.087). Cox regression identified initial aortic size ≥4.0 cm (hazard ratio [HR] 3.028), AAA (HR 2.146), chronic aortic findings (3.589), and the use of topoisomerase inhibitors (HR 2.694). Linear regression demonstrated increased growth rates predicted by antimetabolite chemotherapy (β 0.170), initial aortic size (β 0.086), and abdominal aortic location (β 0.139, all P < 0.002). CONCLUSIONS Small aortic aneurysms with concomitant malignancies are discovered at smaller initial sizes, grow at similar rates, require fewer interventions, and have fewer ruptures and acute dissections than patients without malignancy. Antimetabolite therapies modestly accelerate aneurysmal growth, and patients receiving topoisomerase inhibitors may require earlier repair. Patients with concomitant disease can be confidently treated according to standard institutional aneurysm surveillance protocols. Overall, we recommend treatment of the malignancy before small aortic aneurysm repair as these aneurysms behave similarly to those in patients without malignancy.
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Affiliation(s)
| | - Lisa Kenney
- School of Medicine, Emory University Hospital, Atlanta, GA
| | - Juan M Sarmiento
- Department of Surgery, Emory University Hospital, Atlanta, GA; Winship Cancer Center, Division of Oncologic Surgery, Emory University Hospital, Atlanta, GA
| | - Ravi R Rajani
- Department of Surgery, Emory University Hospital, Atlanta, GA; Division of Vascular Surgery, Emory University Hospital, Atlanta, GA.
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15
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Piqueras L, Sanz MJ. Angiotensin II and leukocyte trafficking: New insights for an old vascular mediator. Role of redox-signaling pathways. Free Radic Biol Med 2020; 157:38-54. [PMID: 32057992 DOI: 10.1016/j.freeradbiomed.2020.02.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/27/2020] [Accepted: 02/03/2020] [Indexed: 12/20/2022]
Abstract
Inflammation and activation of the immune system are key molecular and cellular events in the pathogenesis of cardiovascular diseases, including atherosclerosis, hypertension-induced target-organ damage, and abdominal aortic aneurysm. Angiotensin II (Ang-II) is the main effector peptide hormone of the renin-angiotensin system. Beyond its role as a potent vasoconstrictor and regulator of blood pressure and fluid homeostasis, Ang-II is intimately involved in the development of vascular lesions in cardiovascular diseases through the activation of different immune cells. The migration of leukocytes from circulation to the arterial subendothelial space is a crucial immune response in lesion development that is mediated through a sequential and coordinated cascade of leukocyte-endothelial cell adhesive interactions involving an array of cell adhesion molecules present on target leukocytes and endothelial cells and the generation and release of chemoattractants that activate and guide leukocytes to sites of emigration. In this review, we outline the key events of Ang-II participation in the leukocyte recruitment cascade, the underlying mechanisms implicated, and the corresponding redox-signaling pathways. We also address the use of inhibitor drugs targeting the effects of Ang-II in the context of leukocyte infiltration in these cardiovascular pathologies, and examine the clinical data supporting the relevance of blocking Ang-II-induced vascular inflammation.
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Affiliation(s)
- Laura Piqueras
- Department of Pharmacology, Faculty of Medicine, University of Valencia, Valencia, Spain; Institute of Health Research INCLIVA University Clinic Hospital of Valencia, Valencia, Spain; CIBERDEM-Spanish Biomedical Research Center in Diabetes and Associated Metabolic Disorders, Carlos III Health Institute, Spanish Ministry of Health, Madrid, Spain.
| | - Maria-Jesus Sanz
- Department of Pharmacology, Faculty of Medicine, University of Valencia, Valencia, Spain; Institute of Health Research INCLIVA University Clinic Hospital of Valencia, Valencia, Spain; CIBERDEM-Spanish Biomedical Research Center in Diabetes and Associated Metabolic Disorders, Carlos III Health Institute, Spanish Ministry of Health, Madrid, Spain.
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16
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Guirguis-Blake JM, Beil TL, Senger CA, Coppola EL. Primary Care Screening for Abdominal Aortic Aneurysm: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 322:2219-2238. [PMID: 31821436 DOI: 10.1001/jama.2019.17021] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Ruptured abdominal aortic aneurysms (AAAs) have mortality estimated at 81%. OBJECTIVE To systematically review the evidence on benefits and harms of AAA screening and small aneurysm treatment to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed (publisher supplied only), Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials for relevant English-language studies published through September 2018. Surveillance continued through July 2019. STUDY SELECTION Trials of AAA screening benefits and harms; trials and cohort studies of small (3.0-5.4 cm) AAA treatment benefits and harms. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed abstracts and full-text articles and extracted data. The Peto method was used to pool odds ratios (ORs) for AAA-related mortality, rupture, and operations; the DerSimonian and Laird random-effects model was used to pool calculated risk ratios for all-cause mortality. MAIN OUTCOMES AND MEASURES AAA and all-cause mortality; AAA rupture; treatment complications. RESULTS Fifty studies (N = 323 279) met inclusion criteria. Meta-analysis of population-based randomized clinical trials (RCTs) estimated that a screening invitation to men 65 years or older was associated with a reduction in AAA-related mortality over 12 to 15 years (OR, 0.65 [95% CI, 0.57-0.74]; 4 RCTs [n = 124 926]), AAA-related ruptures over 12 to 15 years (OR, 0.62 [95% CI, 0.55-0.70]; 4 RCTs [n = 124 929]), and emergency surgical procedures over 4 to 15 years (OR, 0.57 [95% CI, 0.48-0.68]; 5 RCTS [n = 175 085]). In contrast, no significant association with all-cause mortality benefit was seen at 12- to 15-year follow-up (relative risk, 0.99 [95% CI 0.98-1.00]; 4 RCTs [n = 124 929]). One-time screening was associated with significantly more procedures over 4 to 15 years in the invited group compared with the control group (OR, 1.44 [95% CI, 1.34-1.55]; 5 RCTs [n = 175 085]). Four trials (n = 3314) of small aneurysm surgical treatment demonstrated no significant difference in AAA-related mortality or all-cause mortality compared with surveillance over 1.7 to 12 years. These 4 early surgery trials showed a substantial increase in procedures in the early surgery group. For small aneurysm treatment, registry data (3 studies [n = 14 424]) showed that women had higher surgical complications and postoperative mortality compared with men. CONCLUSIONS AND RELEVANCE One-time AAA screening in men 65 years or older was associated with decreased AAA-related mortality and rupture rates but was not associated with all-cause mortality benefit. Higher rates of elective surgery but no long-term differences in quality of life resulted from screening.
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Affiliation(s)
- Janelle M Guirguis-Blake
- Department of Family Medicine, University of Washington, Tacoma
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Tracy L Beil
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Caitlyn A Senger
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Erin L Coppola
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
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17
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Wang LJ, Prabhakar AM, Kwolek CJ. Current status of the treatment of infrarenal abdominal aortic aneurysms. Cardiovasc Diagn Ther 2018; 8:S191-S199. [PMID: 29850431 DOI: 10.21037/cdt.2017.10.01] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aortic aneurysms are the 13th leading cause of death in the United States. While aneurysms can occur along the entire length of the aorta, the infrarenal location is the most common. Targeted ultrasound screening has been found to be an effective and economical means of preventing aortic aneurysm rupture. The indication for repair includes either symptomatic aneurysms or aneurysms with a diameter greater than 5.4 cm. Treatment options for the repair of infrarenal aortic aneurysms are open surgical repair (OSR) and endovascular aneurysm repair (EVAR). Currently, EVAR is the primary treatment method for the repair of infrarenal aortic aneurysms due to improved short-term morbidity and mortality outcomes. This article is intended to review the current status of the management of infrarenal abdominal aortic aneurysms (AAA).
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Affiliation(s)
- Linda J Wang
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand M Prabhakar
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Kwolek
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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18
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Zheng X, Liu G, Cui G, Cheng M, Zhang N, Hu S. Angiotensin-Converting Enzyme Gene Deletion Polymorphism is Associated with Lymph Node Metastasis in Colorectal Cancer Patients in a Chinese Population. Med Sci Monit 2017; 23:4926-4931. [PMID: 29032382 PMCID: PMC5655539 DOI: 10.12659/msm.903312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background The purpose of this study was to assess the effect of angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism on the risk of lymph node metastasis (LNM) in colorectal cancer (CRC) patients. Material/Methods We enrolled 146 CRC patients and 106 healthy controls in this study. ACE gene I/D polymorphism was genotyped by polymerase chain reaction (PCR). Hardy-Weinberg equilibrium (HWE) was used to assess the goodness of fit of the genotypes. χ2 test was used to calculate the differences of genotype and allele distributions. Odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs) were used to analyze the association between ACE I/D polymorphism and LNM in CRC patients. Results Insertion/deletion (ID) and deletion/deletion (DD) genotypes were frequently observed in CRC patients, but only DD genotype and D allele were related to the susceptibility of CRC (P=0.038, OR=2.158, 95%CI=1.039–4.480; P=0.026, OR=1.501, 95%CI=1.048–2.150). DD genotype and D allele also increased the risk of LNM in CRC patients (P=0.028, OR=2.844, 95%CI=1.107–7.038; P=0.026, OR=1.692, 95%CI=1.063–2.693). Conclusions DD genotype and D allele of ACE gene I/D polymorphism might increase the risk of LNM in CRC patients.
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Affiliation(s)
- Xiao Zheng
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland).,Department of General Surgery, Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Guoli Liu
- First Department of Geriatrics, Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Gang Cui
- Department of General Surgery, Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Ming Cheng
- Department of General Surgery, Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Nan Zhang
- Department of General Surgery, Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Sanyuan Hu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland)
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19
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Meital LT, Sandow SL, Calder PC, Russell FD. Abdominal aortic aneurysm and omega-3 polyunsaturated fatty acids: Mechanisms, animal models, and potential treatment. Prostaglandins Leukot Essent Fatty Acids 2017; 118:1-9. [PMID: 28288701 DOI: 10.1016/j.plefa.2017.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/30/2017] [Accepted: 02/07/2017] [Indexed: 01/22/2023]
Abstract
Abdominal aortic aneurysm (AAA) is an inflammatory disease associated with macrophage accumulation in the adventitia, oxidative stress, medial elastin degradation and aortic dilation. Progression of AAA is linked to increased risk of rupture, which carries a high mortality rate. Drug therapies trialled to date lack efficacy and although aneurysm repair is available for patients with large aneurysm, peri-surgical morbidity and mortality have been widely reported. Recent studies using rodent models of AAA suggest that long chain omega-3 polyunsaturated fatty acids (LC n-3 PUFAs) and their metabolites can moderate inflammation and oxidative stress perpetuated by infiltrating macrophages and intervene in the destruction of medial elastin. This review examines evidence from these animal studies and related reports of inhibition of inflammation and arrest of aneurysm development following prophylactic supplementation with LC n-3 PUFAs. The efficacy of LC n-3 PUFAs for management of existing aneurysm is unclear and further investigations involving human clinical trials are warranted.
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Affiliation(s)
- Lara T Meital
- Inflammation and Healing Research Cluster, School of Health and Sport Sciences, University of the Sunshine Coast, Queensland, Australia
| | - Shaun L Sandow
- Inflammation and Healing Research Cluster, School of Health and Sport Sciences, University of the Sunshine Coast, Queensland, Australia
| | - Philip C Calder
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Fraser D Russell
- Inflammation and Healing Research Cluster, School of Health and Sport Sciences, University of the Sunshine Coast, Queensland, Australia.
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