Editor's Choice - Systematic Review and Meta-Analysis of Contemporary Abdominal Aortic Aneurysm Growth Rates

The Justification of Open Surgical Repair for an Abdominal Aortic Aneurysm: A Retrospective Comparison of Outcomes of Endovascular Aneurysm Repair and a Brief Review of the Literature

Background: Abdominal aortic aneurysms (AAAs) are life-threatening conditions that require timely intervention to prevent rupture. Endovascular aneurysm repair (EVAR) is preferred due to faster recovery and lower perioperative risk; however, intraoperative failure and long-term complications highlight the continued significance of open surgical repair (OSR) and the need for improved risk assessment. Methods: This retrospective study analyzed data from 210 patients who underwent EVAR (n = 163) or OSR (n = 47) at a single center. Clinical characteristics, complications, reintervention rates, and 30-day mortality were recorded. EVAR-to-OSR conversion and mortality predictors in AAA treatments were identified. Results: The overall mortality rate was 9.5% (20/210 patients), with 12 patients (7.3%) in the EVAR group and 8 patients (17%) in the OSR group (p = 0.085). Five patients required early and six required late conversion to open surgery. In follow-ups beyond 30 days, the reintervention rate for EVAR was higher (HR: 1.2, 95% CI: 0.4-3.6; p = 0.754). According to the multivariable analysis, rupture (p = 0.045), female sex (p = 0.018), body weight (p = 0.003), and aortic size index (p = 0.019) were significant predictors of mortality, whereas OSR was not (p = 0.212). Conclusions: Treatment optimization requires a balanced approach, integrating both EVAR and OSR based on patient-specific factors. Maintaining expertise in both techniques is essential to ensure the best possible outcomes, and OSR should remain a viable option when clinically indicated.

The Impact of Physical Activity on Abdominal Aortic Aneurysm: A Scoping Review

BACKGROUND

Abdominal aortic aneurysm (AAA), a condition primarily affecting older men, is often asymptomatic but becomes life-threatening if rupture occurs. While AAA risk factors such as age, gender, and smoking are well-studied, physical activity (PA) may also play a critical role in managing AAA progression, though this relationship remains understudied. This scoping review aims to synthesize current knowledge on the impact of PA on AAA, examining safety, physiological effects, and potential protective effects against AAA progression.

METHODS

A comprehensive scoping review methodology was applied, covering databases from their inception to October 2024, including MEDLINE, CINAHL, Scopus, and Web of Science. Seven studies meeting the inclusion criteria were analyzed, with intervention designs ranging from cross-sectional to longitudinal studies.

RESULTS

After full-text review of 44 articles, 38 were excluded due to focus on surgical intervention or flow models. The manual screening adding one study, resulting in 7 articles included in this review. PA appears generally safe for individuals with small AAAs, with minimal adverse events reported in most studies, though one study noted a cardiac incident during exercise. PA interventions often improved cardiovascular metrics, including ventilatory threshold and inflammatory markers, yet demonstrated mixed effects on AAA growth. Notably, the protective effect of PA against AAA progression remains inconclusive, requiring further investigation.

CONCLUSIONS

This review indicates that moderate PA is generally safe and may provide health benefits for individuals with small AAAs. However, significant knowledge gaps remain, especially regarding the optimal frequency, intensity, and duration of PA, as well as its long-term impact on aneurysm progression. All these issues require objective measurement of PA to develop targeted physical activity guidelines for this population.

Proprotein convertase subtilisin/kexin type 9 as a drug target for abdominal aortic aneurysm

PURPOSE OF REVIEW

There are no current drug therapies to limit abdominal aortic aneurysm (AAA) growth. This review summarizes evidence suggesting that inhibiting proprotein convertase subtilisin/kexin type 9 (PCSK9) may be a drug target to limit AAA growth.

RECENT FINDINGS

Mendelian randomization studies suggest that raised LDL and non-HDL-cholesterol are causal in AAA formation. PCSK9 was reported to be upregulated in human AAA samples compared to aortic samples from organ donors. PCSK9 gain of function viral vectors promoted aortic expansion in C57BL/6 mice infused with angiotensin II. The effect of altering PCSK9 expression in the aortic perfusion elastase model was reported to be inconsistent. Mutations in the gene encoding PCSK9, which increase serum cholesterol, were associated with increased risk of human AAA. Patients with AAA also have a high risk of cardiovascular death, myocardial infarction and stroke. Recent research suggests that PCSK9 inhibition would substantially reduce the risk of these events.

SUMMARY

Past research suggests that drugs that inhibit PCSK9 have potential as a novel therapy for AAA to both limit aneurysm growth and reduce risk of cardiovascular events. A large multinational randomized controlled trial is needed to test if PCSK9 inhibition limits AAA growth and cardiovascular events.

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.