Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study : The Tromsø Study

Implicit screening of abdominal aortic aneurysms among veterans using lumbar spine MRI

BACKGROUND

Early detection of abdominal aortic aneurysms (AAAs) is critical given the high morbidity and mortality of a ruptured aneurysm. Screening ultrasound is recommended for men 65 and 75 years of age with a smoking history. However, studies have shown that the rate of ultrasound screening is low and that implicit AAA screening by abdominal imaging studies that were not originally intended for AAA screening can play a major role in AAA detection.

OBJECTIVE

The main objective was to evaluate the role of lumbar spine MRIs as an implicit AAA screening study by assessing the detection rate of AAAs in a broader cohort of veterans that included screening and non-screening populations.

METHODS

4085 consecutive lumbar spine MRIs from our institution between 2/2020 and 9/2023 were retrospectively reviewed. Each study was labeled AAA present, AAA not present, or indeterminate by radiologists. The correlation between the presence of AAAs and cardiovascular risk factors was assessed using multinomial logistic regression.

RESULTS

AAAs were present in 89 studies (2.2 %) from 80 patients (mean age 75.8 (56-93), M:F 10:0) and absent in 3935 cases (96.3 %) from 3310 patients (mean age 61.7 (19-100), M:F 9:1). Indeterminate cases (n = 61, 1.5 %) were mainly due to incomplete visualization (70.5 %). Mean AAA size was 3.6 cm with most AAAs (n = 43) smaller than 3.5 cm. Sixteen AAAs were 3.5-3.9 cm, 16 between 4 and 4.9cm, and 6 between 5 and 5.9 cm. Artifact precluded measurements in 8 cases. Among the AAA-positive cases, 20 had no prior documentation of AAA. Twenty-one patients with AAAs would not have met the criteria for the routine AAA screening ultrasound. Higher rates of hypertension, hyperlipidemia, and smoking were observed for the AAA cohort at 78.8 % (OR 2.037, CI 1.160-3.576, P = .013), 82.5 % (2.808, 1.543-5.110, P < .001), and 75 % (3.340, 1.979-5.638, P < .001), respectively, compared to the matched no-AAA cohort (58.2 %, 57.6 %, and 50.8 %; n = 2055).

CONCLUSION

Lumbar spine MRI is a valid modality for implicit screening of AAAs.

CLINICAL IMPACT

Those interpreting lumbar spine MRIs should be vigilant about assessing for AAAs, especially in men with a history of hypertension, hyperlipidemia, or tobacco smoking.

Computed Tomography Angiography for Aortic Diseases

Aortic pathologies encompass a heterogeneous group of disorders, including acute aortic syndrome, traumatic aortic injury , aneurysm, aortitis, and atherosclerosis. The clinical manifestations of these disorders can be varied and non-specific, ranging from acute presentations in the emergency department to chronic incidental findings in an outpatient setting. Given the non-specific nature of their clinical presentations, the reliance on non-invasive imaging for screening, definitive diagnosis, therapeutic strategy planning, and post-intervention surveillance has become paramount. Commonly used imaging modalities include ultrasound, computed tomography (CT), and MR imaging. Among these modalities, computed tomography angiography (CTA) has emerged as a first-line imaging modality owing to its excellent anatomic detail, widespread availability, established imaging protocols, evidence-proven indications, and rapid acquisition time.

Unravelling the role of cathepsins in cardiovascular diseases

Lysosomal cathepsins as a regulatory medium have been assessed as potential therapeutic targets for the treatment of various cardiac diseases such as abdominal aortic aneurysm, hypertension, cardiomyopathy, coronary heart disease, atherosclerosis, etc. They are ubiquitous lysosomal proteases with papain-like folded protein structures that are involved in a variety of physiological processes, such as the digestion of proteins, activation of pro-inflammatory molecules, degradation of extracellular matrix components, and maturation of peptide hormones. Cathepsins are classified into three major groups: cysteine cathepsins, aspartic cathepsins, and serine-threonine cathepsins. Each of these groups is further divided into subgroups based on their substrate specificity, structural characteristics, and biochemical properties. Several studies suggest that cathepsins control the degradation of ECM components such as collagen and elastin fibres. These enzymes are highly expressed in macrophages and inflammatory cells, and their upregulation has been demonstrated to be critical in the progression of atherosclerotic lesions. Additionally, increased cathepsin activity has been linked to increased vascular inflammation and oxidative stress, both of which are associated with CVDs. Specifically, the inhibition of cathepsins may reduce the release of pro-apoptotic mediators such as caspase-3 and PARP-1, which are thought to contribute to plaque instability. The potential of cathepsins as biomarkers and therapeutic targets has also been supported by the identification of potential cathepsin inhibitors, which could be used to modulate the activities of cathepsins in a range of diseases. This review shall familiarise the readers with the role of cysteinyl cathepsins and their inhibitors in the pathogenesis of cardiovascular diseases.

A Case Study of Abdominal Aortic Aneurysm Detection and Critical Vascular Surgery

Abdominal aortic aneurysm, characterized by a persistent dilation exceeding 3 cm or 50% of the aortic diameter, poses a substantial risk, particularly in males over 65. Despite its potentially asymptomatic nature, early detection is imperative due to the elevated mortality rates, reaching 90% following rupture. The presented case involves a 60-year-old male with progressively worsening abdominal pain, a history of cardiovascular disease, hypertension, and smoking. Initial examinations were inconclusive, requiring advanced imaging that revealed a large aneurysmal dilation. Therapeutic measures included endovascular aneurysm repair (EVAR), highlighting the significance of timely intervention. Despite elective surgery risks, mortality rates decrease significantly when the aneurysm diameter surpasses 43 mm. This report stresses the need for primary care physicians to conduct thorough screenings, recognize risk factors, and facilitate prompt referrals for advanced imaging. The case's pivotal lesson lies in the comprehensive management of abdominal aortic aneurysm, showcasing the potential for life-saving interventions and the critical role of early detection in mitigating the severe consequences associated with its rupture.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Myocardial Injury after Non-Cardiac Surgery in Patients Who Underwent Open Repair for Abdominal Aortic Aneurysm: A Retrospective Study

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) has been known to be associated with mortality in various surgical patients; however, its prognostic role in abdominal aortic aneurysm (AAA) open repair remains underexplored. This study aimed to investigate the role of MINS as a predictor of mortality in patients who underwent AAA open repair.

METHODS

This retrospective study investigated 352 patients who underwent open repair for non-ruptured AAA. The predictors of 30-day and 1-year mortalities were investigated using logistic regression analysis.

RESULTS

MINS was diagnosed in 41% of the patients after AAA open repair in this study. MINS was an independent risk factor of 30-day mortality (odds ratio [OR]: 10.440, 95% confidence interval [CI]: 1.278-85.274, p = 0.029) and 1-year mortality (OR: 5.189, 95% CI: 1.357-19.844, p = 0.016). Kaplan-Meier survival curves demonstrated significantly lower overall survival rates in patients with MINS compared to those without MINS (p = 0.003).

CONCLUSION

This study revealed that MINS is a common complication after AAA open repair and is an independent risk factor of 30-day and 1-year mortalities. Patients with MINS have lower overall survival rates than those without MINS.

Multimodal Prehabilitation for Patients Undergoing Endovascular Aortic Aneurysm Repair Surgery: A Feasibility Study

BACKGROUND

Elective treatment options for aortic abdominal aneurysms include open repair or the less-invasive endovascular aortic aneurysm repair (EVAR). Recovery from EVAR is generally considered easier and faster than open repair. Despite this, EVAR remains a major procedure, and average return to preoperative quality of life is at least 3 months. The purpose of this study is to determine the safety and feasibility of multimodal prehabilitation, a multidisciplinary preoperative optimization intervention, in patients undergoing EVAR and its impact on perioperative functional capacity and quality of life.

METHODS

Candidates for EVAR with an infra-renal abdominal aortic aneurysm <7.5cm were invited to participate in a 6-week multimodal prehabilitation program that included (1) supervised and home-based exercise, (2) nutritional support, (3) psychosocial support, and (4) smoking cessation. Functional capacity and quality of life were assessed at baseline, before surgery and 6 weeks postoperatively. Recruitment rate, safety, and compliance were also assessed.

RESULTS

A total of 24 patients were included, 17 males (70%) and 7 females (30%). No adverse events occurred during the program. Compliance to each component of the program (median [Q1-Q3]) was 66% [67] for supervised training, 100% [67] for home-based training, and 100% [100] for nutrition. The multimodal prehabilitation program elicited a significant increase in functional capacity and quality of life preoperatively.

CONCLUSION

Multimodal prehabilitation for patients awaiting EVAR is feasible and safe. Multimodal prehabilitation improves both functional capacity and quality of life preoperatively. Further research is needed to assess the impact of multimodal prehabilitation on postoperative quality of life and functional capacity.

CLINICAL IMPACT

Multimodal prehabilitation is safe and feasible in patients awaiting endovascular aneurysm repair. The importance of this finding is that multimodal prehabilitation can be safely delivered preoperatively in patients awaiting EVAR. Although further research is needed, multimodal prehabilitation seems to improve preoperative functional capacity and quality of life. This could have an impact for the future implementation of prehabilitation interventions in order to increase functional reserve and quality of life preoperatively so that this high-risk population can cope better with the surgical stress and return to their normal life faster postoperatively.

Aneurysm and Artery Dissection After Oral VEGFR-TKI Use in Adults With Cancer

Importance

The association of tyrosine kinase inhibitors targeting vascular endothelial growth factor receptors (VEGFR-TKIs) with aneurysm and artery dissection (AAD) has been frequently reported in spontaneous reporting databases.

Objective

To investigate the risk and incidence of AAD occurrence in patients with cancer treated with oral VEGFR-TKIs, with capecitabine as an active comparator.

Design, Setting, and Participants

This national, historical cohort study was conducted using national claims data from the National Health Insurance Service in Korea from 2007 to 2020, with a 1-year follow-up. Patients with cancer aged 40 years or older prescribed oral VEGFR-TKIs or capecitabine were enrolled. Data were analyzed from September 2022 through April 2023.

Exposure

Oral VEGFR-TKIs (sorafenib, regorafenib, vandetanib, sunitinib, lenvatinib, axitinib, and pazopanib) or capecitabine as a comparator.

Main Outcomes and Measures

Hazard ratios (HRs) were used to investigate the association between VEGFR-TKI use and AAD after propensity score matching. The primary outcome was AAD, and secondary outcomes were aortic aneurysm and dissection and AAD with rupture. Outcomes were defined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes.

Results

Among 127 710 patients with cancer eligible for the study (80 386 males [62.9%]; mean [SD] age, 62.6 [10.9] years), 37 308 patients received VEGFR-TKIs and 90 402 patients received capecitabine. Among 27 535 matched patients receiving VEGFR-TKIs, the incidence of AAD within 1 year of treatment initiation was 6.0 per 1000 person-years. The median (IQR) time to AAD onset in the matched AAD group was 114 (67-257) days after treatment initiation, with the highest incidence observed during the first 3 months (45 incidents vs 31, 17, and 16 incidents during 3- to 6-month, 6- to 9-month, and 9- to 12-month periods, respectively). Cox regression modeling showed that the risk of AAD occurrence was significantly higher among patients prescribed VEGFR-TKIs than those receiving capecitabine (HR, 1.48; 95% CI, 1.08-2.02); similar results were obtained among females (HR, 2.08; 95% CI, 1.26-3.42), older adults (aged ≥65 years; HR, 1.42; 95% CI, 1.01-1.99), and patients with dyslipidemia (HR, 1.58; 95% CI, 1.11-2.24).

Conclusions and Relevance

In this study, the use of oral VEGFR-TKIs was associated with an increased risk of AAD occurrence. These findings elucidate vascular toxic effects and may provide a substantial reference for reducing the socioeconomic burden of adverse events associated with VEGFR-TKI use.

Evidence Accumulates: Patients with Ascending Aneurysms Are Strongly Protected from Atherosclerotic Disease

Ascending thoracic aortic aneurysms may be fatal upon rupture or dissection and remain a leading cause of death in the developed world. Understanding the pathophysiology of the development of ascending thoracic aortic aneurysms may help reduce the morbidity and mortality of this disease. In this review, we will discuss our current understanding of the protective relationship between ascending thoracic aortic aneurysms and the development of atherosclerosis, including decreased carotid intima-media thickness, low-density lipoprotein levels, coronary and aortic calcification, and incidence of myocardial infarction. We also propose several possible mechanisms driving this relationship, including matrix metalloproteinase proteins and transforming growth factor-β.

Association between Loneliness and Memory Function through White Matter Hyperintensities in Older Adults: The Moderating Role of Gender

Loneliness has an important impact on memory function in late life. However, the neural mechanism by which loneliness detrimentally influences memory function remains elusive. Furthermore, it remains unclear whether the association between loneliness and memory function varies by gender. The current study aimed to investigate the neural mechanism underlying the association between loneliness and episodic memory function and explore whether it varies with gender among cognitively normal older adults. A total of 173 community-dwelling adults aged 60 years or older from the Korean Social Life, Health, and Aging Project (KSHAP) study (mean age = 71.87) underwent an assessment of loneliness, neuropsychological testing, and structural magnetic resonance imaging. The association between loneliness and episodic memory function was mediated by the volume of white matter hyperintensities (WMHs), but not by hippocampal or gray matter volumes. In addition, the association between loneliness and memory function through WMHs was significantly moderated by gender; specifically, the indirect effect was significant among men but not among women. The study suggests that WMHs may be a potential neurological mechanism that causes late-life memory dysfunction associated with loneliness in older men. The findings underscore the need for gender-specific interventions to mitigate memory impairment associated with late-life loneliness, with significant public health implications.

C-reactive protein deficiency ameliorates experimental abdominal aortic aneurysms

Background

C-reactive protein (CRP) levels are elevated in patients with abdominal aortic aneurysms (AAA). However, it has not been investigated whether CRP contributes to AAA pathogenesis.

Methods

CRP deficient and wild type (WT) male mice were subjected to AAA induction via transient intra-aortic infusion of porcine pancreatic elastase. AAAs were monitored by in situ measurements of maximal infrarenal aortic external diameters immediately prior to and 14 days following elastase infusion. Key AAA pathologies were assessed by histochemical and immunohistochemical staining procedures. The influence of CRP deficiency on macrophage activation was evaluated in peritoneal macrophages in vitro.

Results

CRP protein levels were higher in aneurysmal than that in non-aneurysmal aortas. Aneurysmal aortic dilation was markedly suppressed in CRP deficient (aortic diameter: 1.08 ± 0.11 mm) as compared to WT (1.21 ± 0.08 mm) mice on day 14 after elastase infusion. More medial elastin was retained in CRP deficient than in WT elastase-infused mice. Macrophage accumulation was significantly less in aneurysmal aorta from CRP deficient than that from WT mice. Matrix metalloproteinase 2 expression was also attenuated in CRP deficient as compared to WT aneurysmal aortas. CRP deficiency had no recognizable influence on medial smooth muscle loss, lymphocyte accumulation, aneurysmal angiogenesis, and matrix metalloproteinase 9 expression. In in vitro assays, mRNA levels for tumor necrosis factor α and cyclooxygenase 2 were reduced in lipopolysaccharide activated peritoneal macrophages from CRP deficient as compared to wild type mice.

Conclusion

CRP deficiency suppressed experimental AAAs by attenuating aneurysmal elastin destruction, macrophage accumulation and matrix metalloproteinase 2 expression.

The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge

BACKGROUND

despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment.

METHODS

we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies.

RESULTS

the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention.

CONCLUSIONS

RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.

Infrarenal Abdominal Aortic Aneurysm

Abdominal aortic aneurysms are found in up to 6% of men and 1.7% of women over the age of 65 years and are usually asymptomatic. The natural history of aortic aneurysms is continued dilation leading to rupture, which is associated with an overall 80% mortality. Of the patients with ruptured aneurysms that undergo intervention, half will not survive their hospitalization. Reduction in aneurysm mortality is therefore achieved by prophylactic repair during the asymptomatic period. On a population-based level, this is supported by abdominal aortic aneurysm screening programs. Approximately 60% of abdominal aortic aneurysms are confined to the infrarenal portion of the aorta and are amenable to repair with off-the-shelf endovascular devices. Endovascular techniques have now replaced open surgery as the primary modality for aneurysm repair.

MR Angiography for Aortic Diseases

Aortic pathologic conditions represent diverse disorders, including aortic aneurysm, acute aortic syndrome, traumatic aortic injury, and atherosclerosis. Given the nonspecific clinical features, noninvasive imaging is critical in screening, diagnosis, management, and posttherapeutic surveillance. Of the commonly used imaging modalities, including ultrasound, computed tomography, and MR imaging, the final choice often depends on a combination of factors: acuity of clinical presentation, suspected underlying diagnosis, and institutional practice. Further research is needed to identify the potential clinical role and define appropriate use criteria for advanced MR applications such as four-dimenional flow to manage patients with aortic pathologic conditions.

Sex differences in specialized pro-resolving lipid mediators and their receptors in abdominal aortic aneurysms

Objective

In this study, we tested the hypothesis that endogenous expression of specialized pro-resolving lipid mediators (SPMs) that facilitate the resolution of inflammation, specifically Resolvin D1and -D2, as well as Maresin1 (MaR1), can impact abdominal aortic aneurysm (AAA) formation and progression in a sex-specific manner.

Methods

SPM expression was quantified in aortic tissue from human AAA samples and from a murine in vivo AAA model via liquid chromatography-tandem mass spectrometry. mRNA expression for SPM receptors FPR2, LGR6, and GPR18 were quantified by real-time polymerase chain reaction. A Student t test with nonparametric Mann-Whitney or Wilcoxon test was used for pair-wise comparisons of groups. One-way analysis of variance after post hoc Tukey test was used to determine the differences among multiple comparative groups.

Results

Human aortic tissue analysis revealed a significant decrease in RvD1 levels in male AAAs compared with controls, whereas FPR2 and LGR6 receptor expressions were downregulated in male AAAs compared with male controls. In vivo studies of elastase-treated mice showed higher levels of RvD2 and MaR1 as well as the SPM precursors, omega-3 fatty acids DHA and EPA, in aortic tissue from males compared with females. FPR2 expression was increased in elastase-treated females compared with males.

Conclusions

Our findings demonstrate that specific differences in SPMs and their associated G-protein coupled receptors exist between sexes. These results indicate the relevance of SPM-mediated signaling pathways in sex differences impacting the pathogenesis of AAAs.

General versus loco-regional anesthesia for endovascular aortic aneurysm repair

BACKGROUND

Aortic aneurysms occur when the aorta, the body's largest artery, grows in size, and can occur in the thoracic or abdominal aorta. The approaches to repair aortic aneurysms include directly exposing the aorta and replacing the diseased segment via open repair, or endovascular repair. Endovascular repair uses fluoroscopic-guidance to access the aorta and deliver a device to exclude the aneurysmal aortic segment without requiring a large surgical incision. Endovascular repair can be performed under a general anesthetic, during which the unconscious patient is paralyzed and reliant on an anesthetic machine to maintain the airway and provide oxygen to the lungs, or a loco-regional anesethetic, for which medications are administered to provide the person with sufficient sedation and pain control without requiring a general anesthetic. While people undergoing general anesthesia are more likely to remain still during surgery and have a well-controlled airway in the event of unanticipated complications, loco-regional anesthesia is associated with fewer postoperative complications in some studies. It remains unclear which anesthetic technique is associated with better outcomes following the endovascular repair of aortic aneurysms.

OBJECTIVES

To evaluate the benefits and harms of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repair.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was 11 March 2022.

SELECTION CRITERIA

We searched for all randomized controlled trials that assessed the effects of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repairs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were: all-cause mortality, length of hospital stay, length of intensive care unit stay. Our secondary outcomes were: incidence of endoleaks, requirement for re-intervention, incidence of myocardial infarction, quality of life, incidence of respiratory complications, incidence of pulmonary embolism, incidence of deep vein thrombosis, and length of procedure. We planned to use GRADE methodology to assess the certainty of evidence for each outcome.

MAIN RESULTS

We found no studies, published or ongoing, that met our inclusion criteria.

AUTHORS' CONCLUSIONS

We did not identify any randomized controlled trials that compared general versus loco-regional anesthesia for endovascular aortic aneurysm repair. There is currently insufficient high-quality evidence to determine the benefits or harms of either anesthetic approach during endovascular aortic aneurysm repair. Well-designed prospective randomized trials with relevant clinical outcomes are needed to adequately address this.

C-reactive protein to albumin ratio provides important long-term prognostic information in patients undergoing endovascular abdominal aortic repair

BACKGROUND

The prognostic value of C-reactive protein/albumin ratio (CAR) is of import in cardiovascular diseases. Our aim was to evaluate the impact of the CAR in patients with asymptomatic abdominal aortic aneurysm (AAA) undergoing endovascular aneurysm repair (EVAR).

MATERIAL AND METHOD

We retrospectively evaluated 127 consecutive patients who underwent technically successful elective EVAR procedure between December 2014 and September 2020. The optimal CAR cut-off value was determined by using receiver operating characteristic (ROC) curve analysis. Based on the cut-off value, we investigated the association of CAR with long-term all-cause mortality.

RESULTS

32 (25.1%) of the patients experienced all-cause mortality during a mean 32.7 ± 21.7 months' follow-up. In the group with mortality, CAR was significantly higher than in the survivor group (4.63 (2.60-11.88) versus 1.63 (0.72-3.24), p < 0.001). Kaplan-Meier curves showed a higher incidence of all-cause mortality in patients with high CAR compared to patients with low CAR (log-rank test, p < 0.001). Multivariable Cox regression analysis revealed that glucose ≥ 110 mg/dL (HR: 2.740; 95% CI: 1.354-5.542; p = 0.005), creatinine ≥ 0.99 mg/dL (HR: 2.957, 95% CI: 1.282-6.819, p = 0.011) and CAR > 2.05 (HR: 8.190, 95% CI: 1.899-35.320, p = 0.005) were the independent predictors of mortality.

CONCLUSION

CAR was associated with a significant increase in postoperative long-term mortality in patients who underwent EVAR. Preoperatively calculated CAR can be used as an important prognostic factor.

Incidence and Outcomes of Abdominal Aortic Aneurysm Repair in New Zealand from 2001 to 2021

Purpose: The burden of abdominal aortic aneurysms (AAA) has changed in the last 20 years but is still considered to be a major cause of cardiovascular mortality. The introduction of endovascular aortic repair (EVAR) and improved peri-operative care has resulted in a steady improvement in both outcomes and long-term survival. The objective of this study was to identify the burden of AAA disease by analysing AAA-related hospitalisations and deaths. Methodology: All AAA-related hospitalisations in NZ from January 2001 to December 2021 were identified from the National Minimum Dataset, and mortality data were obtained from the NZ Mortality Collection dataset from January 2001 to December 2018. Data was analysed for patient characteristics including deprivation index, repair methods and 30-day outcomes. Results: From 2001 to 2021, 14,436 patients with an intact AAA were identified with a mean age of 75.1 years (SD 9.7 years), and 4100 (28%) were females. From 2001 to 2018, there were 5000 ruptured AAA with a mean age of 77.8 (SD 9.4), and 1676 (33%) were females. The rate of hospitalisations related to AAA has decreased from 43.7 per 100,000 in 2001 to 15.4 per 100,000 in 2018. There was a higher proportion of rupture AAA in patients living in more deprived areas. The use of EVAR for intact AAA repair has increased from 18.1% in 2001 to 64.3% in 2021. The proportion of octogenarians undergoing intact AAA repair has increased from 16.2% in 2001 to 28.4% in 2021. The 30-day mortality for intact AAA repair has declined from 5.8% in 2001 to 1.7% in 2021; however, it has remained unchanged for ruptured AAA repair at 31.6% across the same period. Conclusions: This study highlights that the incidence of AAA has declined in the last two decades. The mortality has improved for patients who had a planned repair. Understanding the contemporary burden of AAA is paramount to improve access to health, reduce variation in outcomes and promote surgical quality improvement.

Ruptured abdominal aortic aneurysm, what does the interventional radiologist and vascular surgeon need from our report?

Abdominal aortic aneurysm is defined as a dilatation of the abdominal aorta greater than 3cm. Its prevalence is between 1 and 1.5 cases per 100 people, constituting an important cause of morbidity and mortality. Rare in women, its frequency increases with age and its most frequent location is between the renal arteries and the aorto-iliac bifurcation. Approximately 5% of cases will involve the visceral branches. It is a silent pathological process whose natural evolution is rupture, which often has a fatal outcome and whose diagnosis is part of the pathology that we will find in emergency radiology. The involvement of the radiologist and the preparation of an accurate diagnostic report, as soon as possible, is essential for decision-making by the team in charge of the patient's surgery.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The neglected association between central obesity markers and abdominal aortic aneurysm presence: A systematic review and meta-analysis

Purpose

To review the association between central obesity and abdominal aortic aneurysm (AAA).

Materials and methods

The PubMed, Web of Sciences, Embase, The China national knowledge infrastructure (CNKI), and Cochrane Library were searched up to April 30, 2022. Researches includes investigation of the relationship between central obesity markers and AAA. Included studies must use recognized measures of central obesity, i.e., waist circumference (WC) and waist-to-hip ratio (WHR), or use imaging techniques to calculate abdominal fat distribution, such as computed tomography (CT) imaging.

Results

Eleven clinical researches were identified of which eight discussed the association between physical examination and AAA, and three studies mainly focused on abdominal fat volume (AFV). Seven researches concluded that there was a positive correlation between markers of central obesity and AAA. Three studies found no significant link between markers of central obesity and AAA. One of the remaining studies reported different results for each sex. Three studies pooled in a meta-analysis identified correlation between central obesity and AAA presence (RR = 1.29; 95% confidence interval, 1.14-1.46).

Conclusion

Central obesity plays a role in the risk of AAA. Standardized central obesity markers may be predictors of AAA. However, there was no association between abdominal fat volume and AAA. Additional relevant evidence and specific mechanisms warrant further study.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?IDCRD42022332519, identifier CRD42022332519.

Comparative performance of three comorbidity scores in predicting survival after the elective repair of abdominal aortic aneurysms

BACKGROUND

We aimed to study the discriminative power of 3 comorbidity scores for predicting 5-year survival after the elective repair of aorto-iliac aneurysms (AAA).

METHODS

444 patients with AAA undergoing elective repair (33% open and 67% endovascular) between 2000 and 2020 were reviewed. The Charlson Comorbidity Index (CCI) and subsequent adjustments by Schneeweiss, Quan and Armitage, the Modified Frailty Index (MFI) and the American Society of Anesthesiologists Score (ASA) were calculated from preoperative data. Their association with 5-year survival was analyzed using Cox regression models and their discriminative power and its changes with C statistics and Net Reclassification Index (NRI).

RESULTS

All comorbidity scores were associated with survival after adjusting by age, sex and type of surgical repair: original CCI HR=1.24, P<0.001; Schneeweiss CCI HR=1.23, P<0.001; Quan CCI HR=1.27, P<0.001, Armitage CCI HR=1.46, P<0.001, MFI HR=1.39, P<0.001 and ASA HR=1.68 (P=0.04) and 2.86 (P=0.01) for classes III and IV, respectively. Associated C statistics were of 0.64, 0.65, 0.65, 0.64, 0.61 and 0.59, respectively. Compared with the original CCI, models based on Schneeweiss CCI and Armitage CCI provided minor improvements in NRI (0.32 and 0.23), and the model based on ASA showed lower C statistics (P=0.014) and NRI (-0.30).

CONCLUSIONS

Established comorbidity scores, such as CCI, MFI or ASA, are all associated with 5-year survival after the elective repair of AAAs, being ASA the worst of them. However, their predictive power is in no case sufficient to identify, by themselves, those patients who may not be eligible for intervention on the basis of life expectancy.

Elective Endovascular vs Open Repair for Elective Abdominal Aortic Aneurysm in Patients ≥80 years of Age: A Systematic Review and Meta-Analysis

OBJECTIVE

To provide updated, pooled evidence on clinical outcomes among octogenarians (aged ≥80 years) with abdominal aortic aneurysm (AAA) managed by elective endovascular repair, compared to conventional open repair.

METHODS

PubMed, Embase, and Scopus databases were systematically searched. Studies that were either observational or randomized controlled trials were considered for the review. Included studies were conducted in elderly subjects (≥80 years) with AAA, and clinical and mortality outcomes were compared between endovascular and open surgical repair. Those reporting on outcomes of patients with urgent repair were excluded. The primary outcomes of interest were mortality and risk of complications. The pooled effect sizes were reported as odds ratio (OR) for categorical outcomes and weighted mean difference (WMD) for continuous outcomes. STATA software was used for statistical analysis.

RESULTS

The meta-analysis included 15 studies. Compared to those undergoing open repair, patients receiving endovascular repair had significantly reduced risk of immediate post-operative mortality (OR .23, 95% CI: .20, .27), overall complication (OR .30, 95% CI: .20, .44), cardiac (OR .23, 95% CI: .16, .35), renal (OR .29, 95% CI: .18, .46), pulmonary (OR .14, 95% CI: .09, .21) and bleeding related (OR .59, 95% CI: .42, .83) complications. The risk of mortality at latest follow up (at 36 months and 60 months) was similar in the two groups. The total blood loss (ml) (WMD -1126.47, 95% CI: -1497.81, -755.13), operative time (min) (WMD -29.40, 95% CI: -56.19, -2.62), length of intensive care unit stay (days) (WMD -2.27, 95% CI: -3.43, -2.12) and overall hospital stay (days) (WMD -6.64, 95% CI: -7.60, -5.68) was significantly lower in those undergoing endovascular repair.

CONCLUSIONS

Endovascular repair appears to be better than open repair of AAA in this high-risk, frail population, with respect to short term outcomes. The benefits of reduced risk of short term mortality, complications, and better peri and post-operative outcomes may be considered when making a choice between these two surgical approaches. Randomized controlled trials are needed to provide reliable evidence on the effect of EVAR on long term survival.

Combination of folic acid with nifedipine is completely effective in attenuating aortic aneurysm formation as a novel oral medication

Aortic aneurysms are prevalent and severe vascular diseases with high mortality from unpredicted ruptures, while the only treatment option is surgical correction of large aneurysms with considerable risk. We have shown that folic acid (FA) is highly effective in alleviating development of aneurysms although not sufficient to completely attenuate aneurysm formation. Here, we examined therapeutic effects on aneurysms of combining FA with Nifedipine as novel and potentially more effective oral medication. Oral administration with FA (15 mg/kg/day) significantly reduced incidence of AAA from 85.71% to 18.75% in Ang II-infused apolipoprotein E (apoE) null mice, while combination of FA with Nifedipine (1.5, 5.0 or 20 mg/kg/day) substantially and completely further reduced incidence of AAA to 12.5%, 11.76% and 0.00% respectively in a dose-dependent manner. The combinatory therapy substantially and completely further alleviated enlargement of abdominal aortas defined by ultrasound, vascular remodeling characterized by elastin degradation and adventitial hypertrophy, as well as aortic superoxide production and eNOS uncoupling activity also in a dose-dependent manner, with combination of FA with 20 mg/kg/day Nifedipine attenuating all of these features by 100% to control levels. Aortic NO and H4B bioavailabilities were also dose-dependently further improved by combining FA with Nifedipine. These data establish entirely innovative and robust therapeutic regime of FA combined with Nifedipine for the treatment of aortic aneurysms. The comminatory therapy can serve as a first-in-class and most effective oral medication for aortic aneurysms, which can be rapidly translated into clinical practice to revolutionize management of the devastating vascular diseases of aortic aneurysms known as silent killers.

Vascular smooth muscle RhoA counteracts abdominal aortic aneurysm formation by modulating MAP4K4 activity

Whether a small GTPase RhoA plays a role in the pathology of abdominal aortic aneurysm (AAA) has not been determined. We show here that RhoA expression is reduced in human AAA lesions, compared with normal areas. Furthermore, incidence of AAA formation is increased in vascular smooth muscle cell (VSMC)-specific RhoA conditional knockout (cKO) mice. The contractility of the aortic rings and VSMCs from RhoA cKO mice is reduced, and expression of genes related to the VSMC contractility is attenuated by loss of RhoA. RhoA depletion activates the mitogen-activated protein (MAP) kinase signaling, including MAP4K4, in the aorta and VSMCs. Inhibition of MAP4K4 activity by DMX-5804 decreases AAA formation. Set, a binding protein to active RhoA, functions as an activator of MAP4K4 by sequestering PP2A, an inhibitor of MAP4K4, in the absence of RhoA. In conclusion, RhoA counteracts AAA formation through inhibition of MAP4K4 in cooperation with Set.

Diagnostic and predictive values of circulating tetrahydrobiopterin levels as a novel biomarker in patients with thoracic and abdominal aortic aneurysms

We have previously shown that circulating levels of tetrahydrobiopterin (H4B) function as a robust biomarker for aortic aneurysms in several independent animal models. In the present study, we examined diagnostic and predictive values of circulating H4B levels in human patients of thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA) for the first time, while clinically applicable biomarkers for aortic aneurysms have never been previously available. Ninety-five patients scheduled for TAA repair surgeries and 53 control subjects were recruited at University of California Los Angeles (UCLA) Ronald Regan Medical Center, while 44 control subjects and 29 AAA patients were recruited through National Institute of Health (NIH) National Disease Research Interchange (NDRI) program. We had intriguing observations that circulating H4B levels were substantially lower in TAA and AAA patients, linearly correlated with aortic H4B levels (blood: R = 0.8071, p < 0.0001, n = 75; plasma: R = 0.7983, p < 0.0001, n = 75), and associated with incidence of TAA (blood: adjusted OR 0.495; 95% CI 0.379-0.647; p < 0.001; plasma: adjusted OR 0.501; 95% CI 0.385-0.652; p < 0.001) or AAA (blood: adjusted OR 0.329; 95% CI 0.125-0.868; p = 0.025) after adjustment for other factors. Blood or plasma H4B levels below 0.2 pmol/μg serve as an important threshold for prediction of aortic aneurysms independent of age and gender (for TAA risk - blood: adjusted OR 419.67; 95% CI 59.191-2975.540; p < 0.001; plasma: adjusted OR 206.11; 95% CI 40.956-1037.279; p < 0.001). This threshold was also significantly associated with incidence of AAA (p < 0.001 by Chi-square analysis). In addition, we observed previously unrecognized inverse association of Statin use with TAA, and an association of AAA with arrhythmia. Taken together, our data strongly demonstrate for the first time that circulating H4B levels can serve as a first-in-class, sensitive, robust and independent biomarker for clinical diagnosis and prediction of TAA and AAA in human patients, which can be rapidly translated to bedside to fundamentally improve clinical management of the devastating human disease of aortic aneurysms.

Identification of biomarkers and analysis of infiltrated immune cells in stable and ruptured abdominal aortic aneurysms

Objectives

The mortality rate of abdominal aortic aneurysm (AAA) is extremely high in the older population. This study aimed to identify potential biomarkers of AAA and aortic rupture and analyze infiltration of immune cells in stable and ruptured AAA samples.

Methods

Raw data of GSE47472, GSE57691, and GSE98278 were downloaded. After data processing, the co-expression gene networks were constructed. Gene Ontology and pathway enrichment analysis of AAA- and aortic rupture-related gene modules were conducted using the Database for Annotation, Visualization, and Integrated Discovery. Gene set enrichment analysis (GSEA) and gene set variation analysis (GSVA) were used for further enrichment analysis. The CIBERSORT tool was used to analyze the relative abundance of immune cells in samples. Differentially expressed immune-related genes were analyzed between different samples. Predictive models were constructed via extreme gradient boosting, and hub genes were identified according to feature importance.

Results

Blue and yellow modules were significantly related to AAA, and genes in these modules were associated with the aortic wall and immune response, respectively. In terms of aortic rupture, the most relevant module was significantly enriched in the inflammatory response. The results of GSEA and GSVA suggested that immune cells and the inflammatory response were involved in the development of AAA and aortic rupture. There were significant differences in the infiltration of immune cells and expression levels of immune-related genes among different samples. NFKB1 might be an important transcription factor mediating the inflammatory response of AAA and aortic rupture. After the construction of a predictive model, CD19, SELL, and CCR7 were selected as hub genes for AAA whereas OAS3, IFIT1, and IFI44L were identified as hub genes for aortic rupture.

Conclusion

Weakening of the aortic wall and the immune response both contributed to the development of AAA, and the inflammatory response was closely associated with aortic rupture. The infiltration of immune cells was significantly different between different samples. NFKB1 might be an important transcription factor in AAA and aortic rupture. CD19, SELL, and CCR7 had potential diagnostic value for AAA. OAS3, IFIT1, and IFI44L might be predictive factors for aortic rupture.

Predictive factors for major adverse cardiac and cerebrovascular events in octogenarians after elective endovascular aneurysm repair

OBJECTIVES

The aim of this study was to identify risk factors of major adverse cardiac and cerebrovascular events (MACCE) in octogenarians who received elective endovascular aneurysm repair (EVAR).

METHODS

Consecutive patients aged ≥ 80 years undergoing elective EVAR from 2009 to 2020 were retrospectively evaluated. The primary outcome was long-term MACCE. All independent risk factors for outcomes were determined by multivariate logistic analysis or Cox regression analysis.

RESULTS

A total of 163 patients were enrolled in this study. The median age was 81 (interquartile range, IQR, 80-84) years and 85.9% (140/163) of them were male. MACCE happened in 2.5% (4/163) patients within 30 days. With median follow-up of 28 (IQR, 15-46) months, the incidence of long-term MACCE was 26.4% (43/163). Arrythmia was significantly associated with long-term MACCE (hazard ratio, HR = 2.64, 95% confidence interval, CI, 1.16-6.03, P = .021). Carotid artery disease was found a significant association with 2-year MACCE (odd ratio, OR = 6.50, 95% CI, 1.07-39.51, P = .042). Besides, we found that arrythmia and congestive heart failure (CHF) were predictors for overall survival (arrythmia, HR = 2.56, 95% CI, 1.05-6.28, P = .039; CHF, HR = 8.96, 95% CI, 2.12-37.79, P = .003).

CONCLUSIONS

EVAR in octogenarians had acceptable perioperative risk and long-term outcome. Considering high risk of 2-year MACCE, intervention strategy should be more cautious for patients with carotid artery disease. Octogenarians with arrythmia and CHF should receive stricter postoperative management in case of MACCE.

Point-of-Care Abdominal Ultrasonography (POCUS) on the Way to the Right and Rapid Diagnosis

Point-of-Care ultrasound (POCUS) is based on target ultrasound that is performed wherever a patient is being treated, and by a non-radiologist directly involved in the patient’s care. It is used either for quick diagnosis or procedural guidance. Abdominal pain is one of the most common complaints in emergency departments, and POCUS can help in the differentiation of patients who need additional diagnostic tests or hospital treatment, which eventually reduces the overall costs of health care. POCUS has high sensitivity and specificity in abdominal pathology, it can be helpful in the evaluation of biliary, intestinal, and urinary tract, and it is especially used in trauma. Additionally, the gold standard for abdominal aortic aneurysm detection, follow up and screening is precisely this diagnostic procedure. Unfortunately, the quality of ultrasound examination can be affected by the experience of the physician performing it and the patient’s body weight. There is no doubt that POCUS is being increasingly recognized, but all motivated physicians should be provided with dedicated tutors and enough time for learning. This would certainly help to implement this diagnostic method as a routine in emergency and critical care departments, and significantly shorten the time until definitive diagnosis.

Editor's Choice - Systematic Review and Meta-Analysis of Normal Infrarenal Aortic Diameter in the General Worldwide Population and Changes in Recent Decades

OBJECTIVE

To analyse the characteristics of normal infrarenal aortic diameter (AD) in the general worldwide population, to examine changes over time, and to investigate geographical differences.

DATA SOURCES

PubMed, Cochrane Library, and Web of Science.

REVIEW METHODS

This was a systematic review and meta-analysis of studies published up to October 2020 describing infrarenal AD measured by ultrasound in the general adult population. The study was conducted in accordance with the PRISMA statement and placed no restrictions on geographical location or year of publication. Studies of individuals pre-selected for certain diseases or risk factors and opportunistic screening were excluded. A random effects model was used to estimate pooled mean AD, and meta-regression analysis was used to study the effects of determinants of AD.

RESULTS

Thirty-two studies were included, reporting data for 941 144 individuals (98% were men). The pooled mean AD was 19.4 mm (95% confidence interval [CI] 18.8 - 20.1), being 20.1 mm (95% CI 19.4 - 20.8) in men and 17.8 mm (95% CI 16.5 - 19.1) in women (p < .001). Outer edge to outer edge (OTO) caliper placement method (p = .015) and body surface area (BSA; p = .010) were significantly associated with larger AD. In men, the largest mean AD was observed in Oceania (p < .001) and the smallest in Asia (p < .020). As none of the studies collected data between 2002 and 2007, the studies were divided into two periods: 2001 and before, and 2008 and after. All recent studies were European, with the diameters being significantly smaller (p = .003) in the latter period (18.3 mm [95% CI 17.5 - 19.1] vs. 20.7 mm [95% CI 19.1 - 22.3]). In the meta-regression models, the reduction in AD over time remained significant after adjustment for potential effect modifiers such as sex, age, geographical area, body size, cardiovascular risk factors, and ultrasound method.

CONCLUSION

Mean infrarenal AD in older European adults has decreased significantly in recent decades. Male sex, BSA, and OTO ultrasound measurement method are associated with larger AD, and geographical differences were observed in men.

Correlation Between Proteolytic Activity and Abdominal Aortic Aneurysm Wall Morphology with Intraluminal Thrombus Volume

BACKGROUND

The aim of this study was to examine the influence of intraluminal thrombus (ILT) volume on the level of proteolytic activity and the content of abdominal aortic aneurysm (AAA) wall.

METHODS

The research was designed as a cross-sectional study at the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia in the period from April 2017 to February 2018. During this period, a total of 155 patients with asymptomatic AAA underwent open surgical treatment and 50 were included in the study based on inclusion and exclusion criteria. Before surgery, patients included in the study were examined by MRI. During the operation, samples of ILT and AAA wall were taken for biochemical analysis.

RESULTS

A statistically significant correlation was found between the volume of the ILT and largest AAA diameter (ρ = 0.56; P < 0.001). The correlation of the ILT volume on the anterior wall and the concentration of MMP-9, MMP-2 and NE/ELA in the wall did not find statistical significance. Also, no statistically significant association was found between the volume of ILT and the concentration of ECM proteins (collagen type 3, elastin, proteoglycan) in the corresponding part of the wall. The association of ILT volume with MDA was also of no statistical significance. There was a positive statistical significance found in correlation of volume of ILT and catalase activity in the wall of AAA (ρ = 0.28, P = 0.049).

CONCLUSIONS

The volume of ILT in the aneurysmal sac seemed not to affect the level of proteolytic activity and the content of the aneurysm wall. However, a positive correlation was found between the ILT and the catalase activity. The effect of ILT on the aneurysm wall and its role in the progression of aneurysmal disease should be examined in future studies.

Illuminating the Mechanisms Underlying Sex Differences in Cardiovascular Disease

Sex is a key risk factor for many types of cardiovascular disease. It is imperative to understand the mechanisms underlying sex differences to devise optimal preventive and therapeutic approaches for all individuals. Both biological sex (determined by sex chromosomes and gonadal hormones) and gender (social and cultural behaviors associated with femininity or masculinity) influence differences between men and women in disease susceptibility and pathology. Here, we focus on the application of experimental mouse models that elucidate the influence of 2 components of biological sex-sex chromosome complement (XX or XY) and gonad type (ovaries or testes). These models have revealed that in addition to well-known effects of gonadal hormones, sex chromosome complement influences cardiovascular risk factors, such as plasma cholesterol levels and adiposity, as well as the development of atherosclerosis and pulmonary hypertension. One mechanism by which sex chromosome dosage influences cardiometabolic traits is through sex-biased expression of X chromosome genes that escape X inactivation. These include chromatin-modifying enzymes that regulate gene expression throughout the genome. The identification of factors that determine sex-biased gene expression and cardiometabolic traits will expand our mechanistic understanding of cardiovascular disease processes and provide insight into sex differences that remain throughout the lifespan as gonadal hormone levels alter with age.

D-Dimer Is a Diagnostic Biomarker of Abdominal Aortic Aneurysm in Patients With Peripheral Artery Disease

Background

Etiology and risk factors of peripheral artery disease (PAD) include age, smoking, and hypertension, etc. , which are shared by an abdominal aortic aneurysm (AAA). Concomitance with AAA in patients with PAD is not rare but is easily overlooked in the clinical situation, though management strategies are altered totally. This study aims to investigate diagnostic biomarkers for the prediction of AAA in patients with PAD.

Methods

A total of 684 patients diagnosed with AAA and/or PAD were enrolled and analyzed retrospectively. Each patient with PAD and AAA was gender and age-matched. Demographic data, medical history, and serum laboratory test profiles were obtained. Statistical analysis was performed to determine diagnostic biomarkers of AAA in patients with PAD.

Results

Firstly, 320 patients with PAD-only and 320 patients with AAA-only were compared. Levels of bilirubin and D-Dimer were decreased, while the incidence of diabetes mellitus, levels of fibrinogen, and platelet count were increased significantly in patients with PAD-only compared with those in patients with AAA-only (P &lt; 0.001). Next, 364 patients with PAD (44 patients with AAA) and 364 patients with AAA (44 patients with PAD) were compared. Multivariate logistic regression analysis confirmed the differential distribution of bilirubin, D-dimer, fibrinogen, and platelet count between patients with AAA and patients with PAD (P &lt; 0.05). Receiver operator curves (ROC) showed that the area under the curve (AUC) of total bilirubin, direct bilirubin, D-dimer, fibrinogen, and platelet count was 0.6113, 0.5849, 0.7034, 0.6473, and 0.6785, respectively. Finally, to further validate the predictive efficacy of mentioned markers, a multivariable logistics regression analysis was performed between the PAD only group and the PAD with AAA group. The results suggested increased levels of D-dimer in the PAD with AAA group compared to the PAD only group (OR: 2.630, 95% CI:1.639–4.221; P &lt; 0.001). In particular, the Youden index suggested that the cut-off value of D-dimer for predicting AAA in patients with PAD was 0.675 mg/L with a sensitivity of 76.9% and a specificity of 84.9% (AUC = 0.8673; 95% CI, 0.8106–0.9240, P &lt; 0.001). In all 364 patients with PAD, 41.46% patients were diagnosed AAA when D-dimer is &gt;0.675 mg/L, while only 3.55% patients were diagnosed AAA when D-dimer ≤ 0.675 mg/L.

Conclusions

PAD and AAA exert different clinical and serum profiles; D-dimer (&gt;0.675 mg/L) is a reliable biomarker for the prediction of AAA in patients with PAD.

Large abdominal aortic aneurysm presented with concomitant acute lumbar disc herniation - a case report

The purpose of this case report was to describe chiropractic management of acute lumbar disc herniation in a patient with a large abdominal aortic aneurysm. A 72-year-old male patient presented with low back pain and right lower leg numbness for 12 months. A review of full-spine X-ray and lumbar MRI revealed moderate spondylosis at L2-5, moderate lumbar scoliosis, and a 7.15 cm abdominal aortic aneurysm (AAA). Given the minimum 2-weeks of referral waiting time to receive treatment for AAA, the patient received chiropractic treatment with a hybrid rehabilitation to address the disc herniation causing severe physical disability. Through the treatments, the patient's pain was significantly alleviated with careful consideration of potential risk factors associated with AAA. In addition, the acute disc herniation was successfully managed by a series of chiropractic treatments before and after the operation for AAA. This case supports that low back pain in patients with AAA can be managed by manual therapy, in contrast to a widespread belief that manual therapy is contraindicated in AAA. More case reports of AAA patients with low back pain are warranted to assess the effectiveness and safety of manual therapy along with surgical treatment for AAA.

Disintegrin and Metalloproteinases (ADAMs [A Disintegrin and Metalloproteinase] and ADAMTSs [ADAMs With a Thrombospondin Motif]) in Aortic Aneurysm

Aortic aneurysm is a complex pathology that can be lethal if not detected in time. Although several molecular mechanisms and pathways have been identified to be involved in aortic aneurysm development and growth, the current lack of an effective pharmacological treatment highlights the need for a more thorough understanding of the factors that regulate the remodeling of the aortic wall in response to triggers that lead to aneurysm formation. This task is further complicated by the regional heterogeneity of the aorta and that thoracic and abdominal aortic aneurysm are distinct pathologies with different risk factors and distinct course of progression. ADAMs (a disintegrin and metalloproteinases) and ADAMTS (ADAMs with a thrombospondin motif) are proteinases that share similarities with other proteinases but possess unique and diverse properties that place them in a category of their own. In this review, we discuss what is known on how ADAMs and ADAMTSs are altered in abdominal aortic aneurysm and thoracic aortic aneurysm in patients, in different animal models, and their role in regulating the function of different vascular and inflammatory cell types. A full understanding of the role of ADAMs and ADAMTSs in aortic aneurysm will help reveal a more complete understanding of the underlying mechanism driving aneurysm formation, which will help towards developing an effective treatment in preventing or limiting the growth of aortic aneurysm.

Ultrasonographic Study of the Effects of Essential Hypertension on the Luminal Diameter and Doppler Velocimetric Indices of the Abdominal Aorta in Adults

OBJECTIVE

To investigate the effects of essential hypertension on the luminal diameter (caliber) and Doppler velocimetric indices of the abdominal aorta (AA) in adult patients with systemic hypertension.

MATERIALS AND METHODS

This was a prospective descriptive comparative study of 254 participants (127 with essential hypertension and 127 age/sex-matched controls). Their anthropometric parameters, fasting blood pressure, lipid profile, fasting blood sugar, and triplex sonography of the suprarenal and infrarenal abdominal aorta (Peak systolic velocity, PSV; End-diastolic velocity, EDV; Resistive Index, RI; and luminal diameter) were evaluated.

RESULTS

The mean age of the male subjects was 64.02 ± 10.02 years, while the mean age of the male controls was 63.14 ± 10.52 years (P > 0.05). The mean age of female subjects was 61.23 ± 10.09 years, while the mean age of the female controls was 61.76 ± 10.26 years (P > 0.05). The age group 60 - 69 years had the highest number of subjects and controls. The mean duration of hypertension in the subjects was 12.5 ± 5.2 years. The suprarenal and infrarenal abdominal aortic diameters (AAD) were higher in males than age-matched female counterparts. AAD increased with age mostly in hypertensive male subjects. PSV (in males) and RI (in both sexes) were elevated in hypertensive subjects compared to controls, while EDV (in both sexes) was significantly lower in subjects than controls. Multivariate linear regression showed that age and diastolic blood pressure were significant independent predictors for both suprarenal and infrarenal AADs.

CONCLUSION

Systemic hypertension causes structural and hemodynamic changes in the abdominal aorta which are detectable on triplex sonography.

Genetic Predisposition to Diabetes and Abdominal Aortic Aneurysm: A Two Stage Mendelian Randomisation Study

OBJECTIVE

Observational studies demonstrate an inverse association between type II diabetes and abdominal aortic aneurysm (AAA) for reasons that are unclear. The aim of this study was to clarify the causal association between type II diabetes predisposition and AAA using Mendelian randomisation.

METHODS

Effect estimates for single nucleotide polymorphisms (SNPs) associated with diabetes were obtained from the DIAbetes Meta-ANalysis of Trans-Ethnic association studies (DIAMANTE) consortium to construct a genetic instrumental variable. Corresponding effect estimates for associations of these SNPs with AAA were obtained from the International Aneurysm Consortium comprising six separate AAA genomewide association studies (4 972 cases and 99 858 controls). Mendelian randomisation estimates were calculated using inverse variance, weighted median, and MR-Egger methods, and compared against recently published observational estimates.

RESULTS

A genetic risk score was constructed from 206 SNPs associated with diabetes. All three Mendelian randomisation models showed no effect of genetic liability to diabetes and risk of AAA (inverse variance: odds ratio 1.04 per unit higher log odds, 95% 0.98 - 1.11, p = .19; MR-Egger slope p = .33; weighted median p = .50). Results were similar after excluding the TCF7L2 locus (inverse variance p = .075). Findings from the Mendelian randomisation analysis differed from previous observational reports of an inverse association (pdif < .001).

CONCLUSION

Lifelong genetic predisposition to diabetes does not appear to protect against AAA. These findings differ from traditional epidemiological studies showing an inverse association between diabetes and AAA, for reasons that remain unclear.

Circular RNA Cdyl promotes abdominal aortic aneurysm formation by inducing M1 macrophage polarization and M1-type inflammation

Macrophage polarization plays a crucial role in regulating abdominal aortic aneurysm (AAA) formation. Circular RNAs (circRNAs) are important regulators of macrophage polarization during the development of cardiovascular diseases. How-ever, the roles of circRNAs in regulating AAA formation through modulation of macrophage polarization remain unknown. In the present study, we compared circRNA microarray data under two distinct polarizing conditions (M1 and M2 macrophages) and identified an M1-enriched circRNA, circCdyl. Loss- and gain-of-function assay results demonstrated that circCdyl overexpression accelerated angiotensin II (Ang II)- and calcium chloride (CaCl₂)-induced AAA formation by promoting M1 polarization and M1-type inflammation, while circCdyl deficiency showed the opposite effects. RNA pulldown, mass spectrometry analysis, and RNA immunoprecipitation (RIP) assays were conducted to elucidate the underlying mechanisms by which circCdyl regulates AAA formation and showed that circCdyl promotes vascular inflammation and M1 polarization by inhibiting interferon regulatory factor 4 (IRF4) entry into the nucleus, significantly inducing AAA formation. In addition, circCdyl was shown to act as a let-7c sponge, promoting C/EBP-δ expression in macrophages to induce M1 polarization. Our results indicate an important role for circCdyl-mediated macrophage polarization in AAA formation and provide a potent therapeutic target for AAA treatment.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Targeting Platelet Activation in Abdominal Aortic Aneurysm: Current Knowledge and Perspectives

Abdominal aortic aneurysm (AAA) is a potentially fatal vascular disease that involves complex multifactorial hemodynamic, thrombotic, inflammatory, and aortic wall remodeling processes. However, its mechanisms are incompletely understood. It has become increasingly clear that platelets are involved in pathological processes of vascular diseases beyond their role in hemostasis and thrombosis. Platelet activation with membrane receptors and secreted mediators promotes thrombus formation and the accumulation of inflammatory cells, which may play an important role in the development of AAA by destroying the structural integrity and stability of the vessel wall. Turbulent blood flow in aortic aneurysms promotes platelet activation and aggregation. Platelet count and heterogeneity are important predictive, diagnostic, and prognostic indicators of AAA. We summarize the relationship between platelet activation and AAA development and propose future research directions and possible clinical applications.

Experimental aortic aneurysm severity and growth depend on topical elastase concentration and lysyl oxidase inhibition

Abdominal aortic aneurysm (AAA) formation and expansion is highly complex and multifactorial, and the improvement of animal models is an important step to enhance our understanding of AAA pathophysiology. In this study, we explore our ability to influence aneurysm growth in a topical elastase plus β-Aminopropionitrile (BAPN) mouse model by varying elastase concentration and by altering the cross-linking capability of the tissue. To do so, we assess both chronic and acute effects of elastase concentration using volumetric ultrasound. Our results suggest that the applied elastase concentration affects initial elastin degradation, as well as long-term vessel expansion. Additionally, we assessed the effects of BAPN by (1) removing it to restore the cross-linking capability of tissue after aneurysm formation and (2) adding it to animals with stable aneurysms to interrupt cross-linking. These results demonstrate that, even after aneurysm formation, lysyl oxidase inhibition remains necessary for continued expansion. Removing BAPN reduces the aneurysm growth rate to near zero, resulting in a stable aneurysm. In contrast, adding BAPN causes a stable aneurysm to expand. Altogether, these results demonstrate the ability of elastase concentration and BAPN to modulate aneurysm growth rate and severity. The findings open several new areas of investigation in a murine model that mimics many aspects of human AAA.

Ruptured abdominal aortic aneurysm in a young male patient, a rare case report

Introduction and importance

Abdominal aortic aneurysm (AAA) is commonly a disease of the elderly population with an atherosclerotic aorta. We present a rare case scenario of a large ruptured AAA in a young patient.

Case presentation

A 32-year-old man presented to the Emergency Department with abdominal pain. On examination he had hypotension with a severely tender abdomen. Imaging revealed a ruptured 10 cm abdominal aortic aneurysm (AAA). He underwent an emergency open aneurysm repair and was discharged well on post-operative day 12. Apart from smoking, he had no known significant risk factors contributing to an AAA of such size. Clinical features and family history suggested a possible underlying connective tissue disorder.

Clinical discussion

A painful abdomen and hypotension in a young patient should prompt investigations to rule out a rare but life-threatening diagnosis of a ruptured AAA.

Conclusion

A possible underlying connective tissue disorder should be investigated for in any young patient presenting with an AAA.

•

Early onset of an abdominal aortic aneurysm is rare

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A painful abdomen with hypotension in a young patient should prompt investigation for a possible underlying ruptured abdominal aortic aneurysm

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Clinical features and family history provide clues for a possible connective tissue disorder as the etiology of the aneurysm in younger population

Urgent Repair of a 17.3 cm Inflammatory Abdominal Aortic Aneurysm

We describe a case of delayed presentation of a very large infra-renal inflammatory abdominal aortic aneurysm. This case highlights the importance of early detection and surveillance of aneurysms in rural communities. Definitive management of symptomatic aneurysms is time critical, and any delay such as for the transfer of patients from a rural site can impact patient survival. We present an example of a rare variant of abdominal aortic aneurysm.

Effect of vertebral compression fractures on aortic neck angulation after endovascular aneurysm repair

OBJECTIVE

Aortic neck angulation (ANA) prior to endovascular aneurysm repair (EVAR) and its changes after EVAR are considered important predictors of postoperative complications. We sought to assess the effects of vertebral body height loss on ANA in patients post-EVAR.

METHODS

All patients who had undergone EVAR for infrarenal aortic aneurysms in our institution between August 2010 and December 2018 were assessed. Anterior and posterior vertebral body heights were measured in all patients on preoperative, early postoperative, and follow-up computed tomography scans (T12-L5 vertebral bodies). Patients who had significant height loss in their follow-up period were designated as the Study group. These were matched to a Control group of the same size using propensity-score matching based on age, gender, and duration between follow-up scans. Aortic neck morphology indices including ANA and its changes were measured, and information related to postoperative endoleaks and aneurysm sac size were extracted in the Study and Control groups.

RESULTS

During the follow-up period, 10 of 185 patients had a radiologically significant vertebral body compression fracture. There was no significant difference between the Study (n = 10) and Control groups in age (77.6 ± 6.9 vs 77.2 ± 7.5 years; P = .64), gender (seven males and three females in each group; P = 1.0), duration between postoperative scans (1830 ± 665 vs 1800 ± 670 days; P = .25), preoperative ANA (36.0° ± 15.6° vs 42.4° ± 18.6°; P = .41), and early postoperative ANA (21.9° ± 11.7° vs 20.9° ± 16.3°; P = .72). Changes in ANA in the postoperative period (7.2° ± 11.1° vs -4.7° ± 6.7°; P = .009; power = .838) were significantly higher in the Study group.

CONCLUSION

Post-EVAR vertebral body compression fractures exacerbate ANA. Awareness of this can guide both preoperative assessment and postoperative management and follow-up.

Diabetes is not protective against the formation of unruptured cerebral aneurysm

OBJECTIVES

Diabetes appears to decrease the risk of subarachnoid hemorrhage. However, it is not clear whether diabetes decreases the risk of aneurysm formation. The aim of our study to evaluate the risk of unruptured cerebral aneurysm in patients with diabetes mellitus.

METHODS

We used data from participants who underwent brain magnetic resonance angiography (MRA) and laboratory tests at the Healthcare System Gangnam Center of Seoul National University Hospital between January 2010 and December 2013. From the 17,368 participants who underwent brain MRA, we analyzed 16,337 subjects whose diabetes status could be identified.

RESULTS

The number of participants with diabetes was 2299 (14.1%). The proportion of participants with cerebral aneurysms was 2.3% in the diabetic group and 2.7% in the non-diabetic group, which was not significantly different (P = 0.225). There were no significant differences in the size, location, and multiplicity of aneurysms between the diabetes and control groups. In multivariate logistic regression, older age showed significant risk effects on cerebral aneurysms, but female sex, hypertension, diabetes, obesity, and smoking did not show significant risk effects.

CONCLUSION

In this study, diabetes did not affect the risk of cerebral aneurysm formation. In addition, neither smoking, nor hypertension was a significant risk factor for unruptured cerebral aneurysms. The lack of association between cerebral aneurysm and the traditional risk factors for subarachnoid hemorrhage requires further study. Risk factors for cerebral aneurysm development and those for cerebral aneurysm rupture may be different.

Screening for Abdominal Aortic Aneurysms and Risk Factors in 65-Year-Old Men in Oslo, Norway

Purpose

To investigate the prevalence of and risk factors for abdominal aortic aneurysm (AAA) in 65-year-old men in Oslo, Norway.

Materials and Methods

From May 2011, until September 2019, the annual population of 65-year-old men living in Oslo were invited to an ultrasonographic screening of the abdominal aorta. Candidates received a one-time invitation by mail, including a questionnaire on possible risk factors and comorbidities. Abdominal aortic outer-to-outer diameter and ankle-brachial index were measured by the screening team. Participants were allocated into three groups: non-, sub- and aneurysmal aorta. Written information on recommended follow-up regime was given to participants with an aortic diameter ≥25 mm. Univariate and multivariate analyses of potential risk factors were performed, in addition to descriptive analyses and significance testing.

Results

In total, 19,328 were invited, 13,215 men were screened, of which 12,822 accepted inclusion in the study. Aortic diameter was registered for 12,810 participants and 330 men had aortic diameter ≥30 mm, giving a prevalence of AAA of 2.6% (95% confidence interval (CI) 2.31-2.86). We identified 4 independent risk factors for AAA: smoking (OR = 3.64, 95% CI 2.90-4.58), hypertension (OR = 1.87, 95% CI 1.49-2.35), BMI >30 (OR = 1.02, 95% CI 1.00-1.03), and diabetes mellitus (OR = 0.52, 95% CI 0.35-0.79), the latter showing an inverse association with AAA growth. A subgroup of 862 men with aortic diameters 25-29 mm had a significantly higher prevalence of BMI >25, smoking and family history of AAA, compared to participants with aortic diameter <25 mm.

Conclusion

Among the participants in this study, the prevalence of abdominal aortic aneurysms was 2.6%. Participants with AAA more frequently reported cardiovascular risk factors, and less frequently diabetes mellitus.