Repair of Abdominal Aortic Aneurysms: JACC Focus Seminar, Part 1

Endovascular Aneurysm Repair (EVAR) in Rupture of the Infrarenal Abdominal Aortic Aneurysm (AAA) with Severe Neck Angulation in Conscience of National Health Coverage in Tertiary Referral Hospital in Indonesian: Case Report

An aortic aneurysm is a condition with focal dilation of 50% or more over the normal aortic diameter. The most frequent form of aortic aneurysms is infrarenal. Endovascular aortic aneurysm repair is a valid treatment for treating patients with abdominal aortic aneurysm. Abdominal aortic aneurysms (AAAs) are electively repaired to prevent rupture. We present a case of an elderly man with an impending rupture of intraluminal infrarenal AAA with bilateral common iliac arteries aneurysms. Overall, the patient had completed the procedure and made a good postoperative recovery with fully coverage of Indonesian national health insurance.

Expand the success of screening to reduce aortic aneurysm mortality: progress interpretation and new fronts

Aortic aneurysm is a leading cause of death across the world. Many victicms carry it without knowing. Ruputre of aortic aneurysms leads to devastating sudden death. This brings trauma to families and our society. Based upon sound results out of several cohort studies, US Preventive Services Task Force (USPST) crafted the 1st nationwide abdominal aorta aneurysm (AAA) screening program in 2005. It was renewed and expanded in subsequent revisions in 2014 and 2019. UK and Sweden estalished their own programs as well. Since then, a significant decline in AAA prevalence and mortality has been observed. Two decades into the practice, the state of the art on diagnostics, surgical approaches, and pharmacological options have drastically changed. Patients previously ineligible for treatment or inconclusive on diagnostics now have valid options. The screening program is on the verge for a bold expansion. In this review, we summarize the chroncles leading to the inception of the screening programs, progress in interpretation after implementation including gains, gaps and controversies, advents of new technologies and approaches, new fronts facing us, as well as priorities to be addressed in future phases. Particularly, screening asssys with a clinically tested biomarker, tetrahydrobiopterin (H4B), enables unpresended accessibility, consistency and throughput to accommodate the needs of a larger population. Furthermore, patients with AAAs at size below the eligibility threhold for surgical intervention (e.g., < 5.5 cm) can be treated with novel oral medications. Confronting factors such as changing demographics and COVID-19 aftermath are putting up new challenges. Nevertheless, running a program at national scale demands both unwavering commitment and agile fine-tuning. Technical innovation will be an indispensable chapter of its continued success. The burden of aortic aneurysm-led sudden death is too heavy for any family and the society to bear; it is time to step up our resolve with additional capacities as discussed in the present review.

Tea Polyphenol-Derived Carbon Dots Alleviate Abdominal Aortic Aneurysm Progression by Mitigating Oxidative Stress and Ferroptosis

Abdominal aortic aneurysm (AAA) is a cardiovascular disease with potentially fatal consequences, yet effective therapies to prevent its progression remain unavailable. Oxidative stress is associated with AAA development. Carbon dots have reactive oxygen species-scavenging activity, while green tea extract exhibits robust antioxidant properties. However, the potential of green tea derived carbon dots in mitigating AAA progression has not been fully elucidated. In this study, tea polyphenol carbon dots (TP-CDs) were synthesized via hydrothermal methods and characterized for their antioxidant properties. The antioxidant effects of TP-CDs were evaluated, and TP-CDs' impact on phenotypic transformation, oxidative stress, apoptosis and ferroptosis was investigated comprehensively in an Ang II-induced AAA model, employing techniques such as Western blotting, flow cytometry, and immunohistochemistry. The results revealed that TP-CDs effectively alleviated oxidative stress induced by Ang II stimulation, thereby inhibiting phenotypic transformation, apoptosis, and ferroptosis in vivo. Furthermore, treatment with TP-CDs significantly attenuated AAA progression in a mouse AAA model. Overall, these findings demonstrate that TP-CDs reduced reactive oxygen species levels in the microenvironment and alleviated the progression of AAA, offering a promising therapeutic strategy for this condition.

Metagenomic Analysis of Gut Microbiota for Abdominal Aortic Aneurysm

Objectives: The pathophysiological mechanism of abdominal aortic aneurysm (AAA) remains unclear. We previously reported that Bifidobacterium adolescentis levels were reduced in the feces of patients with AAA by 16S ribosomal ribonucleic acid (RNA) gene sequencing. In this study, we increased the number of cases and conducted metagenomic analyses to examine bacterial genes associated with the pathophysiology of AAA. Methods: For gut microbiota data, feces from 55 patients with AAA and 52 patients with no history of AAA, lower extremity artery disease, or coronary artery disease (control group) were collected. Metagenomic analysis was performed by collecting raw stool samples from patients. For intestinal microbiota analysis, metagenomic analysis of the fecal samples was performed. Results: Oral bacteria, including Actinomyces oris (p <0.0001), Streptococcus salivarius (p <0.001), Lactobacillus salivarius (p <0.001), and Streptococcus sp. (p <0.001), were increased in the feces of patients with AAA. In addition, bacterial genes related to alpha lipoic acid (ALA) biosynthesis (M00882, M00883, and M00884, p <0.0001) were decreased in patients with AAA. Conclusions: In the feces of patients with AAA, there was an increase in oral bacteria, and the expression of bacterial genes related to ALA biosynthesis was reduced. The results suggest the possibility of developing gut microbial drug treatments for AAA.

FGF21 promotes angiotensin II-induced abdominal aortic aneurysm via PI3K/AKT/mTOR pathway

BACKGROUND

Abdominal aortic aneurysm (AAA) is a potentially fatal vascular disorder with a high mortality rate. It was previously reported that fibroblast growth factor 21 (FGF21) was highly expressed in AAA patients. Nonetheless, its underlying mechanism in AAA progression is unclarified.

METHODS

Angiotensin II (Ang-II) was used to induce AAA in human aortic vascular smooth muscle cells (HASMCs) and mouse models. Western blotting and RT-qPCR were utilized for measuring protein and RNA levels. Immunofluorescence staining was utilized for detecting LC3B expression in HASMCs. Elastica van Gieson staining was conducted for histological analysis of the abdominal aortas of mice.

RESULTS

FGF21 displayed a high level in Ang-II-stimulated HASMCs and AAA mice. FGF21 depletion ameliorated abdominal aorta dilation and Ang-II-triggered pathological changes in mice. FGF21 silencing hindered autophagy and PI3K/AKT/mTOR pathway.

CONCLUSIONS

FGF21 contributes to AAA progression by enhancing autophagy and activating PI3K/AKT/mTOR pathway.

A bibliometric and visualization analysis of global trends and frontiers on macrophages in abdominal aortic aneurysms research

BACKGROUND

Macrophages are key regulators of the inflammatory and innate immune responses. Researchers have shown that aberrant expression of macrophages contributes to the development of abdominal aortic aneurysms (AAA). However, a comprehensive bibliometric analysis exploring the research status and knowledge mapping of this area is lacking. This study aimed to explore the research status, knowledge mapping and hotspots of macrophages in AAA research from a bibliometric perspective.

METHODS

In this study, we retrieved articles published between 2000 and 2022 on macrophages associated with AAA research from the Web of Science Core Collection (WoSCC) database. The retrieved literature data were further analyzed using Citespace and VOSviewer software.

RESULTS

A total of 918 qualified publications related to AAA-associated macrophages were retrieved. The number of publications in this field has been increasing annually. China and the United States were the 2 main drivers in this field, contributing to more than 64% of the publications. In addition, the US had the most publications, top institutions, and expert researchers, dominating in research on macrophages in AAA. The Harvard University was the most productive institution, with 60 publications. The journal with the most publications was Arteriosclerosis, Thrombosis, and Vascular Biology (86). Daugherty Alan was the most prolific author (28 publications) and he was also the most cited co- author. Furthermore, the exploration of established animal models, macrophage-related inflammatory-microenvironment, macrophage-related immune mechanism, clinical translation and molecular imaging research remained future research directions in this field.

CONCLUSIONS

Our findings offered new insights for scholars in this field. They will help researchers explore new directions for their work.

Chronic intermittent hypoxia facilitates the development of angiotensin II-induced abdominal aortic aneurysm in male mice

Obstructive sleep apnea (OSA), characterized by episodes of intermittent hypoxia (IH), is highly prevalent in patients with abdominal aortic aneurysm (AAA). However, whether IH serves as an independent risk factor for AAA development remains to be investigated. Here, we determined the effects of chronic (6 mo) IH on angiotensin (Ang II)-induced AAA development in C57BL/6J male mice and investigated the underlying mechanisms of IH in cultured vascular smooth muscle cells (SMCs). IH increased the susceptibility of mice to develop AAA in response to Ang II infusion by facilitating the augmentation of the abdominal aorta's diameter as assessed by transabdominal ultrasound imaging. Importantly, IH with Ang II augmented aortic elastin degradation and the expression of matrix metalloproteinases (MMPs), mainly MMP8, MMP12, and a disintegrin and metalloproteinase-17 (ADAM17) as measured by histology and immunohistochemistry. Mechanistically, IH increased the activities of MMP2, MMP8, MMP9, MMP12, and ADAM17, while reducing the expression of the MMP regulator reversion-inducing cysteine-rich protein with Kazal motifs (RECK) in cultured SMCs. Aortic samples from human AAA were associated with decreased RECK and increased expression of ADAM17 and MMPs. These data suggest that IH facilitates AAA development when additional stressors are superimposed and that this occurs in association with an increased presence of aortic MMPs and ADAM17, potentially due to IH-induced modulation of RECK expression. These findings support a plausible synergistic link between OSA and AAA and provide a better understanding of the molecular mechanisms underlying the pathogenesis of AAA.NEW & NOTEWORTHY IH facilitates Ang II-induced abdominal aortic diameter expansion and AAA development in C57BL/6J male mice. IH upregulates the expression of specific MMPs such as MMP8, MMP12, and ADAM17. IH directly suppresses RECK expression and increases MMPs activity in SMCs. Human AAA tissues exhibit a downregulation of RECK and an upregulation of ADAM17 and MMPs.

A Dual-Targeting, Multi-Faceted Biocompatible Nanodrug Optimizes the Microenvironment to Ameliorate Abdominal Aortic Aneurysm

Abdominal aortic aneurysm (AAA) is a highly lethal cardiovascular disease that currently lacks effective pharmacological treatment given the complex pathophysiology of the disease. Here, single-cell RNA-sequencing data from patients with AAA and a mouse model are analyzed, which reveals pivotal pathological changes, including the M1-like polarization of macrophages and the loss of contractile function in smooth muscle cells (SMCs). Both cell types express the integrin αvβ3, allowing for their dual targeting with a single rationally designed molecule. To this end, a biocompatible nanodrug, which is termed EVMS@R-HNC, that consists of the multifunctional drug everolimus (EVMS) encapsulated by the hepatitis B virus core protein modifies to contain the RGD sequence to specifically bind to integrin αvβ3 is designed. Both in vitro and in vivo results show that EVMS@R-HNC can target macrophages as well as SMCs. Upon binding of the nanodrug, the EVMS is released intracellularly where it exhibits multiple functions, including inhibiting M1 macrophage polarization, thereby suppressing the self-propagating inflammatory cascade and immune microenvironment imbalance, while preserving the normal contractile function of SMCs. Collectively, these results suggest that EVMS@R-HNC presents a highly promising therapeutic approach for the management of AAA.

Comprehensive transcriptomic analysis unveils macrophage-associated genes for establishing an abdominal aortic aneurysm diagnostic model and molecular therapeutic framework

BACKGROUND

Abdominal aortic aneurysm (AAA) is a highly lethal cardiovascular disease. The aim of this research is to identify new biomarkers and therapeutic targets for the treatment of such deadly diseases.

METHODS

Single-sample gene set enrichment analysis (ssGSEA) and CIBERSORT algorithms were used to identify distinct immune cell infiltration types between AAA and normal abdominal aortas. Single-cell RNA sequencing data were used to analyse the hallmark genes of AAA-associated macrophage cell subsets. Six macrophage-related hub genes were identified through weighted gene co-expression network analysis (WGCNA) and validated for expression in clinical samples and AAA mouse models. We screened potential therapeutic drugs for AAA through online Connectivity Map databases (CMap). A network-based approach was used to explore the relationships between the candidate genes and transcription factors (TFs), lncRNAs, and miRNAs. Additionally, we also identified hub genes that can effectively identify AAA and atherosclerosis (AS) through a variety of machine learning algorithms.

RESULTS

We obtained six macrophage hub genes (IL-1B, CXCL1, SOCS3, SLC2A3, G0S2, and CCL3) that can effectively diagnose abdominal aortic aneurysm. The ROC curves and decision curve analysis (DCA) were combined to further confirm the good diagnostic efficacy of the hub genes. Further analysis revealed that the expression of the six hub genes mentioned above was significantly increased in AAA patients and mice. We also constructed TF regulatory networks and competing endogenous RNA networks (ceRNA) to reveal potential mechanisms of disease occurrence. We also obtained two key genes (ZNF652 and UBR5) through a variety of machine learning algorithms, which can effectively distinguish abdominal aortic aneurysm and atherosclerosis.

CONCLUSION

Our findings depict the molecular pharmaceutical network in AAA, providing new ideas for effective diagnosis and treatment of diseases.

Pentamethylquercetin attenuates angiotensin II-induced abdominal aortic aneurysm formation by blocking nuclear translocation of C/EBPβ at Lys253

BACKGROUND

Pentamethylquercetin (PMQ) is a natural polymethyl flavonoid that possesses anti-apoptotic and other biological properties. Abdominal aortic aneurysm (AAA), a fatal vascular disease with a high risk of rupture, is associated with phenotypic switching and apoptosis of medial vascular smooth muscle cells (VSMCs). This study aimed to investigate the protective effects of PMQ on the development of AAA and the underlying mechanism.

METHODS

ApoE-/- mice were continuously infused with angiotensin II (Ang II) for 4 weeks to develop the AAA model. Intragastric administration of PMQ was initiated 5 days before Ang II infusion and continued for 4 weeks. In vitro, VSMCs were cultured and pretreated with PMQ, stimulated with Ang II. Real-time PCR, western blotting, and immunofluorescence staining were used to examine the roles and mechanisms of PMQ on the phenotypic switching and apoptosis of VSMCs.

RESULTS

PMQ dose-dependently reduced the incidence of Ang II-induced AAA, aneurysm diameter enlargement, elastin degradation, VSMCs phenotypic switching and apoptosis. Furthermore, PMQ also inhibited phenotypic switching and apoptosis in Ang II-stimulated VSMCs. PMQ exerted protective effects by regulating the C/EBPβ/PTEN/AKT/GSK-3β axis. AAV-mediated overexpression of PTEN reduced the therapeutic effects of PMQ in the AAA model mice, suggesting that the effects of PMQ on Ang II-mediated AAA formation were related to the PTEN/AKT/GSK-3β axis. PMQ inhibited VSMCs phenotypic switching and apoptosis by bounding to C/EBPβ at Lys253 with hydrogen bond to regulate C/EBPβ nuclear translocation and PTEN/AKT/GSK-3β axis, thereby inhibiting Ang II-induced AAA formation.

CONCLUSIONS

Pentamethylquercetin inhibits angiotensin II-induced abdominal aortic aneurysm formation by bounding to C/EBPβ at Lys253. Therefore, PMQ prevents the formation of AAA and reduces the incidence of AAA.

M1 Macrophage-Derived Exosome LncRNA PVT1 Promotes Inflammation and Pyroptosis of Vascular Smooth Muscle Cells in Abdominal Aortic Aneurysm by Inhibiting miR-186-5p and Regulating HMGB1

Abdominal aortic aneurysm (AAA) is a chronic vascular degenerative disease. Vascular smooth muscle cells (VSMCs) are essential for maintaining the integrity of healthy blood vessels. Macrophages play an important role in the inflammatory process of AAA. However, the effect of macrophage-derived exosome LncRNA PVT1 on VSMCs is unclear. Exosomes from M1 macrophages (M1φ-exos) were isolated and identified. The expression of LncRNA PVT1 in M1φ-exos was determined. AAA cell model was constructed by treating VSMCs with Ang-II. AAA cell model was treated with M1φ exosomes transfected with si-LncRNA PVT1 (M1φsi-LncRNA PVT1-exo). VSMCs were transfected with miR-186-5p mimic and oe-HMGB1. Cell viability was detected by CCK-8. The accumulation of LDH was detected by ELISA. Western blot was used to detect the expression of HMGB1, inflammatory factors (IL-6, TNF-α and IL-1β) and pyroptosis-related proteins (GSDMD, N-GSDMD, ASC, NLRP3, Caspase-1 and Cleaved-Capase-1). Cell pyroptosis rate was detected by flow cytometry. At the same time, the targeting relationship between miR-186-5p and LncRNA PVT1 and HMGB1 was verified by double fluorescein experiment. Exosomes from M1φ were successfully extracted. The expression of LncRNA PVT1 in M1φ-exos was significantly increased. M1φ-exo promotes inflammation and pyroptosis of VSMCs. M1φsi-LncRNA PVT1-exos inhibited the inflammation and pyroptosis of VSMCs. LncRNA PVT1 can sponge miR-186-5p mimic to regulate HMGB1 expression. MiR-186-5p mimic further inhibited inflammation and pyroptosis induced by M1φsi-LncRNA PVT1-exos. However, oe-HMGB1 could inhibit the reversal effect of miR-186-5p mimic. LncRNA PVT1 in exosomes secreted by M1φ can regulate HMGB1 by acting as ceRNA on sponge miR-186-5p, thereby promoting cell inflammatory and pyroptosis and accelerating AAA progression.

Pathogenesis and management of abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) causes ∼170 000 deaths annually worldwide. Most guidelines recommend asymptomatic small AAAs (30 to <50 mm in women; 30 to <55 mm in men) are monitored by imaging and large asymptomatic, symptomatic, and ruptured AAAs are considered for surgical repair. Advances in AAA repair techniques have occurred, but a remaining priority is therapies to limit AAA growth and rupture. This review outlines research on AAA pathogenesis and therapies to limit AAA growth. Genome-wide association studies have identified novel drug targets, e.g. interleukin-6 blockade. Mendelian randomization analyses suggest that treatments to reduce low-density lipoprotein cholesterol such as proprotein convertase subtilisin/kexin type 9 inhibitors and smoking reduction or cessation are also treatment targets. Thirteen placebo-controlled randomized trials have tested whether a range of antibiotics, blood pressure-lowering drugs, a mast cell stabilizer, an anti-platelet drug, or fenofibrate slow AAA growth. None of these trials have shown convincing evidence of drug efficacy and have been limited by small sample sizes, limited drug adherence, poor participant retention, and over-optimistic AAA growth reduction targets. Data from some large observational cohorts suggest that blood pressure reduction, particularly by angiotensin-converting enzyme inhibitors, could limit aneurysm rupture, but this has not been evaluated in randomized trials. Some observational studies suggest metformin may limit AAA growth, and this is currently being tested in randomized trials. In conclusion, no drug therapy has been shown to convincingly limit AAA growth in randomized controlled trials. Further large prospective studies on other targets are needed.

Elevated triglyceride-glucose index predicts mortality following endovascular abdominal aortic aneurysm repair

Background

Triglyceride-glucose (TyG) index has been increasingly studied as a simple and reliable predictor of adverse events of some cardiovascular disorders. However, its prognostic effect on postoperative outcomes in patients with abdominal aortic aneurysm (AAA) is still unknown. The current study aimed to explore the potential role of TyG index in predicting mortality of AAA patients following endovascular aneurysm repair (EVAR).

Materials and methods

This retrospective cohort study analyzed the preoperative TyG index in a total of 188 AAA patients who underwent EVAR with the follow-up of 5 years. Data were analyzed with SPSS software Version 23.0. Association between the TyG index and all-cause mortality was evaluated using Cox regression models and Kaplan-Meier method.

Results

Cox regression analyses showed that per 1-unit increment of TyG index was significantly associated with an increased risk of postoperative 30-day, 1-year, 3-year, and 5-year mortality, even after adjustment for potential confounders (all P<0.05). Kaplan-Meier analysis suggested that patients with high TyG index (≥8.68) had a worse overall survival (P = 0.007).

Conclusion

The elevated TyG index could be a promising predictive factor of postoperative mortality in AAA patients after EVAR.