Statins reduce extensive aortic atheromas in patients with abdominal aortic aneurysms

Effect of statins on abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) is a prevalent condition which causes progressive growth and rupture of aortic wall with a high death rate. Several studies have found that treatment with statins may decrease the progress of AAA and the risk of rupture by suppressing the inflammatory mediators, decreasing oxidative stress, and inhibiting mechanisms involved in extracellular matrix (ECM) degradation. Moreover, some studies have reported that prehospital therapy with statins can decrease mortality after surgery. The novelty of this paper is that different studies including those performed in humans and animals were reviewed and the potential mechanisms by which statins can have an effect on AAA were summarized. Overall, the evidence suggested an association between treatment with statins and improvement of AAA.

Effect of Atheromatous Aorta on Thromboembolic Complications after Endovascular Aortic Aneurysm

Objective: The purpose of this study was to evaluate the effect of atheromatous aorta on thromboembolic complications after endovascular aortic aneurysm repair (EVAR) and to assess the risk factors for these complications. Materials and Methods: This retrospective study included patients who underwent EVAR for an abdominal aortic aneurysm at the Shizuoka Red Cross Hospital from 2007 to 2018. We defined atheromatous aorta as a thoracic shaggy aorta or abdominal aorta with neck thrombus. The main outcome was renal dysfunction and peripheral embolization (thromboembolic complications). We compared the incidence of thromboembolic complications between patients with normal aorta and atheromatous aorta. Moreover, we assessed the risk factors associated with thromboembolic complications in patients with atheromatous aorta. Results: Patients with atheromatous aorta had significantly more thromboembolic complications, such as renal dysfunction (24.5% vs. 3.9%; P<0.001) and peripheral embolization (12.3% vs. 0.0%; P<0.001) than those with normal aorta, respectively. We identified no risk factors associated with thromboembolic complications in patients with atheromatous aorta. Conclusion: Atheromatous aorta increases the risk of thromboembolic complications after EVAR. However, there is no established therapy for these thromboembolic complications. Further studies are necessary to determine the appropriate therapy, including appropriate preoperative medication, to prevent these complications.

The Shaggy Aorta Syndrome: An Updated Review

BACKGROUND

Shaggy aorta (SA) depicts the severe aortic surface degeneration, extremely friable, and likely to cause spontaneous peripheral and visceral embolization or during catheterization, aortic manipulation, surgery, or minimally invasive procedures. This study aims to provide the most accurate and up-to-date information on this disease.

METHODS

Potentially eligible studies to be included were identified by searching the following databases: CENTRAL Library, ClinicalTrials.gov, MEDLINE, and CINAHL, using a combination of subject headings and text words to identify relevant studies: (Shaggy aorta) OR (aortic embolization) OR (aortic embolism) OR (aortic thrombus) OR (aortic plaque). From a total of 29,111 abstracts, and after applying inclusion and exclusion criteria, we considered 60 studies for inclusion in this review.

RESULTS

Appropriate measurement and assessment of the aortic wall are pivotal in the modern era, in particular when percutaneous procedures are performed, as SA has been identified as an independent risk factor for spinal cord injury, mesenteric embolization, and cerebral infarction after endovascular aortic repair. Furthermore, SA increases the rate of cerebral complications during transcatheter aortic valve implantation.

CONCLUSIONS

In conclusion, prompt diagnosis of SA syndrome and appropriate guidelines on the management of these conditions may help physicians to better assess the patient risk and to minimize the dreadful-related complications.

A case of anastomotic stenosis of the small intestine caused by cholesterol crystal embolism

Background

Cholesterol crystal embolism (CCE) is caused by small crystals of cholesterol dispersed from atherosclerotic plaques of the aorta. There is an increasing interest in CCE because of the increased use of endovascular treatments. Here, we report a rare case of intestinal stenosis caused by CCE after functional end-to-end anastomosis (FEEA). To our knowledge, this is the first report of CCE causing such an anastomotic stenosis.

Case presentation

A 77-year-old male patient underwent laparoscopy-assisted low anterior resection and protective ileostomy for rectal carcinoid tumor. He was admitted to our hospital with ileus 1 year after stoma closure. Eosinophils and creatine kinase level were slightly elevated. Computed tomography revealed a stricture with thickened intestinal wall just distal to the anastomosis site of the ileostomy. The wall of the descending aorta appeared shaggy due to thrombosis. The patient underwent laparoscopic small-bowel resection because ileus reoccurred after any oral intake.

Histopathological findings of the resected specimen showed fibrotic changes distal to the anastomosis site, and needle-shaped cholesterol embolus was observed in the submucosal layer. Thus, the stenosis was considered to be caused by CCE.

Conclusion

This appears to be the first published report of stenosis due to CCE at such an anastomotic site. Intestinal CCE is difficult to diagnose preoperatively and is associated with poor prognosis. If eosinophilia is present or shaggy aorta is observed, CCE should be suspected to make correct diagnosis and prevent recurrence of CCE.

Beneficial effect of statins on total mortality in abdominal aortic aneurysm (AAA) repair

In this single center, retrospective cohort study we wished to compare early and total mortality for all patients treated for abdominal aortic aneurysms (AAA) with open surgery who were taking statins compared to those who were not. A cohort of 640 patients with AAA was treated with open surgery between 1999 and 2012. Patients were consecutively recruited from a source population of 390,000; 21.3% were female, and the median age was 73 years. The median follow-up was 3.93 years, with an interquartile range of 1.79–6.58 years. The total follow-up was 2855 patient-years. An explanatory strategy was used. The propensity score (PS) was implemented to control for selection bias and confounders. The crude effect of statin use showed a 78% reduction of the 30-day mortality. A stratified analysis using the Mantel–Haenszel method on quintiles of the PS gave an adjusted effect of the odds ratio equal to 0.43 (95% CI: 0.18–0.96), indicating a 57% reduction of the 30-day mortality for statin users. The adjusted rate ratio was 0.62 (95% CI: 0.45–0.83), indicating a reduction of long-term mortality of 38% for statin users compared to non-users for a median follow-up of 3.93 years. This retrospective cohort study showed a significant beneficial effect of statin use on early and long-term survival for patients treated with open surgery. To be conclusive, our results need to be replicated by a randomized clinical trial.

Effect of statins on early and late clinical outcomes of carotid endarterectomy and the rate of post-carotid endarterectomy restenosis

BACKGROUND

This study analyzed the effect of statins on clinical outcomes after carotid endarterectomy (CEA) and the rate of restenosis.

STUDY DESIGN

We performed a retrospective analysis of prospectively collected data on 500 consecutive CEAs followed at 1, 6, and 12 months and every year.

RESULTS

There were 299 patients on statins vs 201 without. Combined perioperative MI/death rates were 2.7% vs 4% (p = 0.416) and MI/stroke/death rates were 4% vs 5% (p = 0.607) for statins vs no statins. At mean follow-up (27 months), MI, stroke, and death rates were: 9.7%, 2.3%, and 2.3% vs 9%, 2.5% and 4.5% (p = 0.18) for statins vs no statins, respectively. Diabetic patients not on statins had 4 times more deaths (8.5% vs 2.3%) and twice as many strokes/deaths (10.2% vs 5.3%). Patients with hypercholesterolemia who were not on statins had twice as many deaths (4.3% vs 2.2%). Rates of freedom from stroke/MI/death at 1, 2, 3, and 4 years were: 94%, 90%, 85% and 77% vs 94%, 89%, 85%, and 82% (p = 0.87) for statins vs no statins, respectively. Rates of freedom from death only for patients on statins vs no statins at 1, 2, 3, and 4 years were: 98%, 98%, 97.4% and 97.4% vs 98%, 96%, 94.8% and 94.8%, respectively (p = 0.191). For diabetic patients, rates of freedom from death at 1, 2, 3, and 4 years were 99%, 99%, 97%, and 97% for statins vs 97%, 90%, 90%, and 90% without statins, respectively (p = 0.048). Post-CEA restenosis rates ≥ 50% were not significantly different between statins vs no statins (p = 0.64).

CONCLUSIONS

Statins significantly lowered death rates in patients with diabetes and tended to lower both death and stroke rates in diabetic patients and patients with hypercholesterolemia. Statins had no effect on post-CEA restenosis.