Management of Inflammatory Aortic Aneurysms - A Scoping Review

Abdominal aortic aneurysm histomorphology shows different inflammatory aspects among patients and is not associated with classic risk factors - the HistAAA study

AIMS

Abdominal aortic aneurysm (AAA) treatment is upon a diameter threshold. Attempts for medical growth abrogation have failed thus far. This study aims to elucidate the heterogeneity of AAA histomorphology in correlation to individual patient and aneurysm metrics.

METHODS AND RESULTS

Samples from the left anterior aneurysm wall underwent histologic analysis including angiogenesis, calcification, fibrosis, type and grade of inflammation in adventitia and media. Clinical information and state of aneurysm (intact, symptomatic, ruptured, inflammatory) were retrieved. Semi-automated geometric analysis (Endosize©, Therenva) and finite element methods (A4Clinics© Research Edition, Vascops GmbH) were included.364 patients' samples (85.4% male, median age 69 years) were scored for acute or chronic inflammation, both not associated with rupture (52x), symptomatic disease (37x) or diameter (57 [52-69] mm; p = 0.87). The degree of fibrosis and the presence of angiogenesis were significantly higher (both p < 0.001) with increasing inflammation, which in turn significantly decreased with patient age (est = - 0.015/year, p = 0.017). No significant differences were seen for acute (vs. elective), male (vs. female) or diabetic patients. Aneurysm geometry (n=252) or annual growth rate (n=142) were not associated with histologic characteristics. Yet, local luminal thrombus formation was significantly higher with increasing inflammation (p = 0.04).

CONCLUSION

Type and degree of inflammation are the most distinguishable histologic characteristics in the AAA wall between individual patients, yet are not associated with diameter or rupture. Local luminal thrombus formation is associated with inflammatory features and suggests a vivid bio-physical compartment with intra-individual age-dependent differences.

Atherosclerotic Abdominal Aortic Aneurysms on Computed Tomography Angiography: A Narrative Review on Spectrum of Findings, Structured Reporting, Treatment, Secondary Complications and Differential Diagnosis

Atherosclerotic abdominal aortic aneurysms (AAAs) are a common vascular pathology with significant morbidity and mortality risks. Timely diagnosis, accurate characterization, and standardized reporting are critical for effective management and monitoring of atherosclerotic AAAs. Imaging modalities, particularly computed tomography angiography (CTA), play a pivotal role in the detection, treatment planning, and identification of both primary and secondary complications, as well as distinguishing AAAs from other etiologies. This narrative review provides a comprehensive exploration of the spectrum of imaging findings in atherosclerotic AAAs on CTA, underscoring the importance of structured reporting. Additionally, it examines therapeutic approaches and complications, and it differentiates AAAs from inflammatory, mycotic, and traumatic variants, serving as a primer for radiologists in AAA evaluation.

Ruptured abdominal aortic aneurysm in psoriasis: A case report and review of literature

INTRODUCTION

Psoriasis, a chronic inflammatory skin condition, affects 4 % of the population and is associated with various comorbidities, making it a public health concern.

CASE REPORT

We discuss the case of a 50-year-old man with severe erythrodermic psoriasis who presented with a ruptured saccular abdominal aortic aneurysm (AAA), requiring emergency surgery with good postoperative follow-up. shedding light on the link between psoriasis and cardiovascular complications.

DISCUSSION

Psoriasis severity correlates with cardiovascular risk and shares common development pathways with aortic aneurysms such as systemic and aortic inflammation, and arterial stiffness, emphasizing the importance of managing both skin symptoms and systemic inflammation to reduce vascular comorbidities. Psoriasis patients have a higher risk of AAA, warranting consideration for AAA screening. Controversies exist regarding corticosteroid therapy and choice of surgical intervention for AAA in psoriatic patients.

CONCLUSION

Psoriasis patients face an increased risk of AAA, highlighting the need for vigilant screening and comprehensive management. Further research is essential to understanding the pathophysiological connections between psoriasis and arterial diseases, guiding preventive strategies and optimal medical treatments for these high-risk patients.

Periaortitis Secondary to Evar: Case Report and Literature Review

CLINICAL IMPACT

Even if periaortitis secondary to EVAR is a very rare complication, it is important for the surgeon to know this possible rare complication and its characteristics, in order to immediately recognize it and treat it adequately to avoid complications.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

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.

Heterogeneous Characteristics of Patients with Inflammatory Abdominal Aortic Aneurysm. Systematic Review of Therapeutic Solutions

BACKGROUND

Endovascular repair of inflammatory abdominal aortic aneurysms (IAAAs) has emerged as an alternative to open surgery, but direct comparisons are limited. The aim of the study was to compare clinical outcomes of endovascular and open repair for IAAA according with specific clinical characteristics.

METHODS

We performed a literature review of reports describing patients who had open or endovascular repair for IAAA. A literature search was performed in June 2022 by 2 investigators who conducted a review of papers reported in PubMed, Embase, MEDLINE, and Cochrane Database. The strings "Inflammatory aneurysm" and "Abdominal Aortic Aneurysms" were used. There was no language restriction and screened reports were published from March 1972 to December 2021. We identified 2,062 patients who had open (1,586) or endovascular repair (476) for IAAA. Primary outcomes were operative mortality and morbidity. Secondary outcomes were complications during follow-up (mean follow-up: 48 months). Propensity score matching was performed between patients who had open or endovascular surgery.

RESULTS

In Western countries, propensity-weighted postoperative mortality (in-hospital) (1.5% endovascular vs. 6% open) and morbidity rates (6% vs. 18%) were significantly lower in patients who had endovascular repair (P < 0.0001); patients with larger aneurysm (more than 7 cm diameter), signs of active inflammation, and retroperitoneal rupture of the aneurysm had better outcomes after endovascular repair than after open surgery. Hydronephrosis was present in 20% of the patients. Hydronephrosis regressed in most patients when signs of active inflammation were present suggesting an acute onset of the hydronephrosis itself (fever, elevated serum C Reactive Protein) either after endovascular or open surgery. Long-standing hydronephrosis as suggested by the absence of signs of active inflammation rarely regressed after endovascular surgery despite associated steroid therapy. During a mean follow-up of 48 months, propensity-weighted graft-related complications were more common in patients who had endovascular repair (20% vs. 8%). For patients from Asia, short-term and medium-term results were similar after open and endovascular repair. IAAAs related with aortitis were more common in Asia. In Western countries, IAAAs were commonly associated with atherosclerosis.

CONCLUSIONS

Patients with IAAA represent a heterogeneous population, suggesting biological differences from continent to continent; conservative therapy and endovascular or open surgery should be chosen according to the patient clinical condition. Endovascular repair presents advantages in patients with signs of active inflammation and contained rupture of the IAAA and larger aneurysms. Hydronephrosis, without signs of active inflammation, rarely regresses after endovascular repair associated with steroid therapy. Further studies are needed to establish the long-term results of endovascular repair.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

The Incidence of IgG4-Related and Inflammatory Abdominal Aortic Aneurysm Is Rare in a 101 Patient Cohort

Abdominal aortic aneurysms (AAA) are the most frequent aortic dilation, with considerable morbidity and mortality. Inflammatory (infl) and IgG4-positive AAAs represent specific subtypes of unclear incidence and clinical significance. Here, histologic and serologic analyses with retrospective clinical data acquisition are investigated via detailed histology, including morphologic (HE, EvG: inflammatory subtype, angiogenesis, and fibrosis) and immunhistochemic analyses (IgG and IgG4). In addition, complement factors C3/C4 and immunoglobulins IgG, IgG2, IgG4 and IgE were measured in serum samples and clinical data uses patients' metrics, as well as through semi-automated morphometric analysis (diameter, volume, angulation and vessel tortuosity). A total of 101 eligible patients showed five (5%) IgG4 positive (all scored 1) and seven (7%) inflammatory AAAs. An increased degree of inflammation was seen in IgG4 positive and inflAAA, respectively. However, serologic analysis revealed no increased levels of IgG or IgG4. The operative procedure time was not different for those cases and the short-term clinical outcomes were equal for the entire AAA cohort. Overall, the incidence of inflammatory and IgG4-positive AAA samples seems very low based on histologic and serum analyses. Both entities must be considered distinct disease phenotypes. Short-term operative outcomes were not different for both sub-cohorts.