Current status of the treatment of infrarenal abdominal aortic aneurysms

Routine Use of Indwelling Urinary Catheters During Endovascular Abdominal Aortic Aneurysm Repair is Not Necessary

OBJECTIVE

Endovascular infra-renal abdominal aortic aneurysm repair (EVAR) has proven to be an effective, less invasive alternative to open aortic aneurysm repair with decreased 30-day mortality. Historically, urinary drainage catheters were routinely placed preoperatively before EVAR in our institution. A shift to reduced catheter placement has occurred in conjunction with percutaneous EVARs becoming more routine. Urethral catheterization carries risk of infection (UTI), urinary retention and prostatic trauma inducing hematuria. The purpose of this study was to evaluate whether avoidance of urinary catheter placement during EVAR is an effective practice to reduce cost and morbidity.

METHODS

This was a single-institution, retrospective review of 177 consecutive patients who underwent elective infrarenal EVAR. Ruptured aneurysms and emergent EVAR were excluded. The study end points were postoperative UTI, urinary retention, length of stay, and readmission within 30 days. Univariable analysis was performed for these four outcomes in patients with (N = 92 and without (N = 65) preoperative urinary catheter placement. A more expansive multivariable investigation for risk of urinary retention following EVAR was conducted with binary logistic regression with co-variates including age, sex, femoral cutdown, estimated blood loss (EBL), urinary catheter, congestive heart failure, diabetes, and postoperative urinary retention as co-variates.

RESULTS

Patients who had a Urinary catheter placed had an over two fold higher event rate of urinary retention (10.9% vs 4.6%) This urinary retention trend lacked power to reach significance (OR 2.52 (.665-9.55). Placement of urinary catheter also had a strong trend towards increased rate of UTI but lacking power for significance (7.6% vs 3.10%, OR 1.96 (.556-6.57). There was no difference with or without urinary catheter placement regarding 30-day readmission (yes catheter 7.6% vs no catheter 6.2%, P = .725), or length of stay (yes catheter 2.13 days vs no catheter 1.74 days, P = .723). Urinary retention was significantly associated with the development of a UTI with 23% of patients who had retention developing UTI compared with 4.2% of patients without retention developing UTI (adjusted odds ratio = 17.98, P = .019). Increased blood loss (P = .027) was also associated with increased rate of UTI on multivariable analysis.

CONCLUSIONS

Avoidance of preoperative urinary catheter placement displays a trend towards avoiding urinary retention and UTI. Patients who develop post EVAR urinary retention experience a significantly increased rate of UTI. Selective urinary catheter placement should be used to help reduce urinary-related complications following elective EVAR.

Long-term results of endovascular versus open retroperitoneal repair associated with ERAS protocol for abdominal aortic aneurysms

OBJECTIVES

Although the endovascular management of infrarenal abdominal aortic aneurysms (AAAs) is widely performed, many studies have shown better long-term results with open graft repairing, mostly focusing on the classical open repair with midline access. This study aims to evaluate long-term results comparing EVAR (endovascular aneurysm repair) and surgical open repair with retroperitoneal access associated with ERAS (Enhanced Recovery After Surgery) protocol.

METHODS

A retrospective analysis of 156 patients treated for AAA between 2015 and 2018 was conducted. Clinical and demographic characteristics of the two groups were homogeneous except for age, which was significantly higher in patients belonging to the EVAR one, and for previous laparotomies. A total of 100 patients (58.7%) underwent open retroperitoneal repair (ORR group), and 56 (42.3%) underwent EVAR. A mean of 51 ± 28 months of follow-up was conducted. This study aims to evaluate long-term survival by comparing EVAR (endovascular aneurysm repair) and surgical open repair with retroperitoneal access associated with ERAS (Enhanced Recovery After Surgery) protocol. Secondary aims evaluate differences between the two techniques regarding late complications, need for re-interventions, and perioperative results.

RESULTS

Freedom from all-cause mortality, calculated with Kaplan-Meier survival curves equalizing the two population with a Covariate Propensity Score, showed significant better survival rates at 1, 3, and 5 years in ORRs then in EVARs. Late complications (>30 days) and need for late re-intervention rates were greater in the EVAR group (6 late re-interventions needed vs 0 in the ORR group).Perioperative results show longer mean length of hospital stay in patients belonging to the ORR group (5 days vs 2) and significantly higher in-hospital-complication rate.

CONCLUSIONS

The long-term comparison between EVAR and open retroperitoneal repair shows significantly better late outcomes in the ORR group. The perioperative course appears significantly better in EVARs but anyway good in ORRs when a perioperative protocol as ERAS is applied.In a selected population of young patients fit for surgery, the retroperitoneal surgical approach should be highly taken into account in the therapeutical choice.

Empowering junior doctors: A study on the feasibility and efficacy of ultrasound AAA screening in rural Australia

PURPOSES

Abdominal Aortic Aneurysm (AAA) screening via ultrasound in Caucasian males aged 65 and older has proven cost-effective in metropolitan areas. Evidence suggests that with adequate training, individuals without prior sonography experience can achieve accurate aortic measurements. This study evaluates the capability of junior doctors, after brief training, to conduct reliable AAA ultrasound screenings in a rural hospital setting, addressing the gap in speciality surgical services.

METHODS

Three junior doctors participated in a 2-hour practical ultrasound training, subsequently performing scans on both inpatients and community volunteers at a regional hospital. The analysis focused on measurement discrepancies within a 5 mm clinically acceptable difference, scanning efficiency, and aneurysm detection accuracy.

RESULTS

A total of 71 participants were included. Among the screenings, 81.7% fell within the clinically acceptable discrepancy range, with 72.7% accuracy in inpatient scans and 95.5% in volunteer scans. Measurement reproducibility improved significantly with the standardisation of ultrasound techniques, and there was excellent agreement among operators in detecting aneurysms. Notably, scanning efficiency improved from the inpatient group to the volunteer group with statistical significance.

CONCLUSIONS

Junior doctors demonstrated the ability to efficiently and reproducibly measure the infrarenal aortic diameter at a level comparable to experienced sonographers after only 2 hours of training. A single day of supervised practice is recommended to ensure standardised ultrasound technique. This approach offers a practical, cost-effective supplement to specialist radiology services in rural areas, enhancing access to critical screening procedures without proposing the replacement of professional sonographers.

JNK2 silencing lipid nanoparticles for elastic matrix repair

The over-expression of c-Jun N-terminal kinase (JNK2), a stress activated mitogen kinase, in the aortic wall plays a critical role in the formation and progression of abdominal aortic aneurysm (AAA). This triggers chronic downstream upregulation of elastolytic matrix metalloproteinases (MMPs), MMPs2 and 9 to cause progressive proteolytic breakdown of the wall elastic matrix. We have previously shown that siNRA knockdown of JNK2 gene expression in an AAA culture model stimulates downstream elastin gene expression, elastic fiber formation, crosslinking and reduces elastolytic MMPs2 and 9. Since naked siRNA poorly routes to intracellular targets, has poor stability in blood, and could be potentially toxic and immunogenic, this project is aimed to develop PEGylated lipid nanoparticles (LNPs) for delivery of JNK siRNA and to generate evidence of successful JNK2 knockdown and downstream attenuation of MMP2 gene and protein expressions. LNPs were formulated using thin-film hydration technique and had the size of 100-200 nm with zeta-potential ranging between 30 and 40 mV. JNK siRNA loaded PEGylated LNPs successfully knocked down JNK2 in cytokine-activated rat aneurysmal smooth muscle (EaRASMC) cultures. This resulted in a downstream decrease in MMP2 gene and protein expression and an upward trend in expression of genes for proteins critical for elastic fiber assembly such as elastin (ELN) and lysyl oxidase (LOX). Our result indicates cationic LNPs to be potential carriers for JNK siRNA delivery improving potency for elastin homeostasis required for AAA repair which could possibly provide benefits in preventing the progression of small AAAs.

Perioperative Mortality and the Long-Term Outcome of Endovascular Abdominal Aneurysm Repair (EVAR): A Single-Centre Experience

Background Abdominal aortic aneurysm (AAA) is a dangerous disorder characterised by abnormal enlargement of the abdominal aorta. The severity of the aneurysm and the presence of symptoms determine the necessary monitoring or treatment to prevent potential fatalities. The objective of this study is to estimate the perioperative mortality and long-term outcome of endovascular abdominal aneurysm repair (EVAR). Patients and methods This is a descriptive, retrospective, observational study. We retrieved the data of the AAA patients who underwent EVAR at Glan Clwyd Hospital from January 2015 to January 2023. The study sample consisted of patients diagnosed with isolated AAA, with or without iliac branch involvement, who were deemed suitable for EVAR based on factors such as advanced age, presence of comorbidities, the complexity of the condition, history of prior surgery, fulfillment of indication criteria, and patient desire. The data was analysed using SPSS statistical software, version 21.0 (IBM Corp., Armonk, NY). Results Two hundred and twenty-two patients were studied. The outcome of the EVAR among the patients was endo-leak 28.4% (n = 63); migration 1.4% (n = 3); blockage 0.5% (n = 1); infolding 0.5% (n = 1); perioperative mortality 1.4% (3); and other complications like access site or acute kidney injury were 1.4% (n = 3). However, no complications were reported in most of the patients, 66.7% (n = 148). Upon evaluating the variables that could affect the outcome, we observed that the ASA grade, comorbidities, and the indication of the intervention had a significant effect on the outcome (P values = 0.000, 0.048, and 0.014, respectively). Conclusion The findings demonstrate that when EVAR is performed by a skilled team adhering to proper criteria, the results are optimal. The mortality rate during the perioperative period was 1.4%. Furthermore, we have shown a satisfactory rate of complications when compared to international data.

Disturbed hemodynamics and oxidative stress interaction in endothelial dysfunction and AAA progression: Focus on Nrf2 pathway

Hemodynamic shear stress is one of the major factors that are involved in the pathogenesis of many cardiovascular diseases including atherosclerosis and abdominal aortic aneurysm (AAA), through its modulatory effect on the endothelial cell's redox homeostasis and mechanosensitive gene expression. Among important mechanisms, oxidative stress, endoplasmic reticulum stress activation, and the subsequent endothelial dysfunction are attributed to disturbed blood flow and low shear stress in the vascular curvature and bifurcations which are considered atheroprone regions and aneurysm occurrence spots. Many pathways were shown to be involved in AAA progression. Of particular interest from recent findings is, the (Nrf2)/Keap-1 pathway, where Nrf2 is a transcription factor that has antioxidant properties and is strongly associated with several CVDs, yet, the exact mechanism by which Nrf2 alleviates CVDs still to be elucidated. Nrf2 expression is closely affected by shear stress and was shown to participate in AAA. In the current review paper, we discussed the link between disturbed hemodynamics and its effect on Nrf2 as a mechanosensitive gene and its role in the development of endothelial dysfunction which is linked to the progression of AAA.

Reference values for paediatric abdominal aorta on B-mode ultrasound - an outer-to-outer methodology

BACKGROUND

B-mode ultrasound is versatile and safe. The sequelae of aortic disorders in children range from stunted growth in hypoplasia to 90% fatality in ruptured aneurysms. Thus, age-based reference values are necessary for early detection of abnormal aortic dimensions.

OBJECTIVE

To create age-based reference values of paediatric aorta diameters from B-mode ultrasound using the outer-to-outer method.

MATERIALS AND METHODS

A retrospective review was done of records of peak systolic anteroposterior aortic diameters, obtained during abdominal ultrasound in children ages 2 days to 17 years between January 2016 and December 2019. Cases were grouped into five age groups.

RESULTS

A total of 643 cases (49% female) were recruited into the study. Only 488 cases (76%) had values for the proximal, mid and distal aorta. The cumulative mean age was 9.5±5.1 years while the mean aortic diameter ranged from 0.3 cm to 1.8 cm. Tables of aortic diameters and reference ranges are presented. There was no significant sex difference. Significant positive correlation was only seen between age and aortic diameters (Pearson's r ranges from 0.66 to 0.91).

CONCLUSION

An age-based paediatric aortic reference table from B-mode ultrasound using outer-to-outer measurement in a Nigerian population is reported.

Abdominal Aortic Thrombus Segmentation in Postoperative Computed Tomography Angiography Images Using Bi-Directional Convolutional Long Short-Term Memory Architecture

Abdominal aortic aneurysm (AAA) is a fatal clinical condition with high mortality. Computed tomography angiography (CTA) imaging is the preferred minimally invasive modality for the long-term postoperative observation of AAA. Accurate segmentation of the thrombus region of interest (ROI) in a postoperative CTA image volume is essential for quantitative assessment and rapid clinical decision making by clinicians. Few investigators have proposed the adoption of convolutional neural networks (CNN). Although these methods demonstrated the potential of CNN architectures by automating the thrombus ROI segmentation, the segmentation performance can be further improved. The existing methods performed the segmentation process independently per 2D image and were incapable of using adjacent images, which could be useful for the robust segmentation of thrombus ROIs. In this work, we propose a thrombus ROI segmentation method to utilize not only the spatial features of a target image, but also the volumetric coherence available from adjacent images. We newly adopted a recurrent neural network, bi-directional convolutional long short-term memory (Bi-CLSTM) architecture, which can learn coherence between a sequence of data. This coherence learning capability can be useful for challenging situations, for example, when the target image exhibits inherent postoperative artifacts and noises, the inclusion of adjacent images would facilitate learning more robust features for thrombus ROI segmentation. We demonstrate the segmentation capability of our Bi-CLSTM-based method with a comparison of the existing 2D-based thrombus ROI segmentation counterpart as well as other established 2D- and 3D-based alternatives. Our comparison is based on a large-scale clinical dataset of 60 patient studies (i.e., 60 CTA image volumes). The results suggest the superior segmentation performance of our Bi-CLSTM-based method by achieving the highest scores of the evaluation metrics, e.g., our Bi-CLSTM results were 0.0331 higher on total overlap and 0.0331 lower on false negative when compared to 2D U-net++ as the second-best.

Identification of Novel Plasma Biomarkers for Abdominal Aortic Aneurysm by Protein Array Analysis

Abdominal aortic aneurysm (AAA) is a potentially life-threatening disease that is common in the aging population. Currently, there are no approved diagnostic biomarkers or therapeutic drugs for AAA. We aimed to identify novel plasma biomarkers or potential therapeutic targets for AAA using a high-throughput protein array-based method. Proteomics expression profiles were investigated in plasma from AAA patients and healthy controls (HC) using 440-cytokine protein array analysis. Several promising biomarkers were further validated in independent cohorts using enzyme-linked immunosorbent assay (ELISA). Thirty-nine differentially expressed plasma proteins were identified between AAA and HC. Legumain (LGMN) was significantly higher in AAA patients and was validated in another large cohort. Additionally, "AAA without diabetes" (AAN) patients and "AAA complicated with type 2 diabetes mellitus" (AAM) patients had different cytokine expression patterns in their plasma, and nine plasma proteins were differentially expressed among the AAN, AAM, and HC subjects. Delta-like protein 1 (DLL1), receptor tyrosine-protein kinase erbB-3 (ERBB3), and dipeptidyl peptidase 4 (DPPIV) were significantly higher in AAM than in AAN. This study identified several promising plasma biomarkers of AAA. Their role as therapeutic targets for AAA warrants further investigation.

Computed Tomography Angiography Markers and Intraluminal Thrombus Morphology as Predictors of Abdominal Aortic Aneurysm Rupture

Background: Abdominal aortic aneurysm (AAA) is a complex vascular disease characterized by progressive and irreversible local dilatation of the aortic wall. Currently, the indication for repair is linked to the transverse diameter of the abdominal aorta, using computed tomography angiography imagery, which is one of the most used markers for aneurysmal growth. This study aims to verify the predictive role of imaging markers and underlying risk factors in AAA rupture. Methods: The present study was designed as an observational, analytical, retrospective cohort study and included 220 patients over 18 years of age with a diagnosis of AAA, confirmed by computed tomography angiography (CTA), admitted to Vascular Surgery Clinic of Mures County Emergency Hospital in Targu Mures, Romania, between January 2018 and September 2022. Results: Patients with a ruptured AAA had higher incidences of AH (p = 0.006), IHD (p = 0.001), AF (p < 0.0001), and MI (p < 0.0001), and higher incidences of all risk factors (tobacco (p = 0.001), obesity (p = 0.02), and dyslipidemia (p < 0.0001)). Multivariate analysis showed that a high baseline value of all imaging ratios markers was a strong independent predictor of AAA rupture (for all p < 0.0001). Moreover, a higher baseline value of DAmax (OR:3.91; p = 0.001), SAmax (OR:7.21; p < 0.001), and SLumenmax (OR:34.61; p < 0.001), as well as lower baseline values of DArenal (OR:7.09; p < 0.001), DACT (OR:12.71; p < 0.001), DAfemoral (OR:2.56; p = 0.005), SArenal (OR:4.56; p < 0.001), SACT (OR:3.81; p < 0.001), and SThrombusmax (OR:5.27; p < 0.001) were independent predictors of AAA rupture. In addition, AH (OR:3.33; p = 0.02), MI (OR:3.06; p = 0.002), and PAD (OR:2.71; p = 0.004) were all independent predictors of AAA rupture. In contrast, higher baseline values of SAmax/Lumenmax (OR:0.13; p < 0.001) and ezetimibe (OR:0.45; p = 0.03) were protective factors against AAA rupture. Conclusions: According to our findings, a higher baseline value of all imaging markers ratios at CTA strongly predicts AAA rupture and AH, MI, and PAD highly predicted the risk of rupture in AAA patients. Furthermore, the diameter of the abdominal aorta at different levels has better accuracy and a higher predictive role of rupture than the maximal diameter of AAA.

Ruptured abdominal aortic aneurysm treated with open surgical repair (OSR) of a patient with active COVID-19 infection: A case report

Introduction and importance

Aim

Case presentation

Clinical discussion

Conclusion

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Coronavirus disease is a viral infection that could induce different respiratory, gastrointestinal, and vascular problems.

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Patients continued to present vascular emergencies during the COVID-19 outbreak.

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An abdominal aortic aneurysm rupture is considered a devastating lethal emergency.

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The COVID-19 pandemic has changed many guidelines in the management of vascular emergencies.

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The global strategy is mandatory despite the lack of equipment, supplies and availability of personnel.

Morphometric characteristics of the aorta and heart in situs inversus totalis

Situs inversus totalis is a rare condition of visceral transposition in thoracic and abdominal cavities. Computed tomography (CT)-based morphometric analysis of the cardiovascular system prior to the surgery helps to describe vessel topography and size, choose the right surgical insertion site, avoid vessel trauma, and prevent hemorrhage during surgical intervention. We present a case report of situs inversus totalis detected incidentally in a 74-year-old male with the acute abdominal syndrome. Appropriate detailed aorta measurements are used to choose an adequate size of the aortic prosthesis during open surgical repair or endovascular aneurysm repair. An accurate assessment of the vessels on CT scans assists in consideration of the catheter diameter and the most reliable cannulation site. Vessel size correlates with morphological conditions (kinking, stenosis, occlusion), which may be considered a risk of organ malperfusion. The anatomical analysis prior to surgery in different anatomical variations may ensure patient safety and predict complications.

Creating Interactive Three-Dimensional Applications to Visualise Novel Stent Grafts That Aid in the Treatment of Aortic Aneurysms

Three-Dimensional (3D) medical animations incorporated into applications are highly beneficial for clinical outreach and medical communication purposes that work towards educating the clinician and patient. Aortic aneurysms are a clinically important area to communicate with multiple audiences about various treatment options; both abdominal and thoracic aortic aneurysms were selected to create 3D animations and applications to educate medical professionals and patients regarding treatment options. Fenestrated endovascular aortic repair (FEVAR) and thoracic endovascular aortic repair (TEVAR) are both tried and tested minimally invasive surgical methods for treating thoracic aortic aneurysms respectively. The Terumo Aortic Custom Relay Proximal Scalloped stent graft and Fenestrated Anaconda stent graft were both designed specifically for these procedures; however, it can be difficult to visually communicate to clinicians and patients in a straightforward way how these devices work. Therefore, we have developed two interactive applications that use 3D visualisation techniques to demonstrate how these aortic devices function and are implemented. The objective of these applications is to engage both clinicians and patients, therefore demonstrating that the addition of anatomically accurate 3D visualisations within an interactive interface would have a positive impact on public engagement while also ensuring that clinicians will have the best possible understanding of the potential uses of both devices, enabling them to exploit their key features to effectively broaden the treatable patient population.Detailed anatomical modelling and animation was used to generate realistic and accurate rendered videos showcasing both products. These videos were integrated into an interactive application within a modern, professional graphic interface that allowed the user to explore all aspects of the stent device. The resulting applications were broken down into three modules: deployment, clinical performance and features. Following application development, these applications were evaluated by professionals in the field. Overall, positive feedback was received regarding the user-friendly nature of the applications and highly effective animations to showcase the products. The clinical applications and feature modules were particularly successful, while the deployment modules had a neutral response. Biomedical applications such as these show great potential for communicating the key features of medical devices and promoting discussion between clinicians and patients; further testing would need to be conducted on a larger group of participants in order to validate the learning effectiveness of the applications.

Five-year survival after elective open and endovascular aortic aneurysm repair

BACKGROUND AND OBJECTIVE

Current evidence suggests short-term survival benefit from endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) in elective abdominal aortic aneurysm (AAA) procedures, but this benefit is lost during long-term follow-up. The aim of this study was to compare short- and mid-term all-cause mortality in patients with non-ruptured aneurysm treated by OSR and EVAR; and to assess the rate of complications and reinterventions, as well as to evaluate their impact on survival.

METHODS

The medical records of the non-ruptured AAA patients undergoing OSR or EVAR between 1 January 2011 and 31 December 2019 at Tartu University Hospital, Estonia, were retrospectively reviewed. We gathered survival data from the national registry (mean follow-up period was 3.7 ± 2.3 years).

RESULTS

A total of 225 non-ruptured AAA patients were treated operatively out of whom 95 (42.2%) were EVAR and 130 (57.8%) were OSR procedures. The difference in estimated all-cause mortality between the OSR and EVAR groups at day 30 was statistically irrelevant (2.3% vs 0%; p = 0.140), but OSR patients showed statistically significantly higher 5 year survival compared with EVAR patients (75.3% vs 50.0%, p = 0.002). Complication and reintervention rates for the EVAR and OSR groups did not differ statistically (26.3% vs 16.9%, p = 0.122; 10.5% vs 11.5%, p = 0.981, respectively). Multivariate analysis revealed that greater aneurysm diameter (p = 0.012), EVAR procedure (p = 0.016), male gender (p = 0.023), and cerebrovascular diseases (p = 0.028) were independently positively associated with 5-year mortality.

CONCLUSIONS

Thirty-day mortality, and complication and reintervention rates for EVAR and OSR after elective AAA repair were similar. Although the EVAR procedure is an independent risk factor for 5-year mortality, higher age and greater proportion of comorbidities among EVAR patients may influence not only the choice of treatment modality, but also prognosis.

Completion of Target Vessel Stenting After FEVAR via Snare Technique in a Patient with Tortuous Right Renal Artery

Target vessel catheterization remains challenging in patients with complex anatomies. Fenestrated endovascular aneurysm repair (FEVAR) is an established technique to treat aortic aneurysms. In this case report, we treated a juxtarenal aneurysm using FEVAR. Initial attempts to complete the target vessel stenting were unsuccessful because of an unfavorable orifice and tortuosity of the right renal artery. The completion of FEVAR was achieved with a bifemoral approach using a snare system, which aligned the tip of a steerable sheath at the level of the fenestration for the right renal artery to create a stable condition. Control angiography and computed tomography confirmed a successful stenting of the target vessel and the sealing of the fenestration without an endoleak.

Associations of global DNA methylation and homocysteine levels with abdominal aortic aneurysm: A cohort study from a population-based screening program in Sweden

Abdominal aortic aneurysm (AAA) is a life-threatening condition with a mortality rate of over 80%. Persistent smoking, which is a risk factor for AAA, has lasting effects on DNA methylation. Moreover, a plasma-amino acid, homocysteine, previously implicated in vascular diseases, including aneurysms, has well-established biological association with methylation. In the present study, we aimed to determine the global DNA methylation, homocysteine levels and their association with AAA and its growth. Enzyme-linked immunosorbent assay (ELISA) was used to quantify global DNA methylation in whole blood-DNA samples and diagnostic enzymatic assay quantified plasma homocysteine, from 65-year old men with (n = 116) and without AAA (n = 230) diagnosed at ultrasound screening. We found significantly higher global DNA methylation (p < .001) and homocysteine levels (p < .001) in men with AAA compared to those without AAA, and direct linear associations with baseline aortic diameter. On multivariable regression analysis, global DNA methylation (odds ratio [OR]: 1.8; 95% confidence interval [CI]: 1.1-2.9) and homocysteine levels (OR: 1.1; 95% CI:1.0-1.1) were positively associated with AAA, independent of smoking, medication use, and major co-morbidities. However, we did not find any significant association between DNA methylation or homocysteine levels with AAA growth during follow-up. We found that global DNA methylation and homocysteine levels are higher in men with AAA but are not associated with AAA growth. This indicates that different pathways and mechanisms may be involved in initiation and progression of AAA. More studies are needed to understand the precise role of DNA methylation, homocysteine and their interplay in AAA pathophysiology.

Simultaneous resection of abdominal aortic aneurysm and left renal cell carcinoma: A rare case and review of the literature

We report a rare case of concomitant abdominal aortic aneurysm (AAA) and left renal cell carcinoma (RCC). The patient was an 81-year old man who presented with vague abdominal pain. The investigations revealed a 110*73*62 mm AAA together with 69*56 left renal mass. Open repair of AAA with left radical nephrectomy was conducted. A simultaneous procedure is safe and does not increase morbidity and mortality in selected cases.

Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: A Comprehensive Review

Abdominal aortic aneurysm (AAA) can be defined as an abnormal, progressive dilatation of the abdominal aorta, carrying a substantial risk for fatal aneurysmal rupture. Endovascular aneurysmal repair (EVAR) for AAA is a minimally invasive endovascular procedure that involves the placement of a bifurcated or tubular stent-graft over the AAA to exclude the aneurysm from arterial circulation. In contrast to open surgical repair, EVAR only requires a stab incision, shorter procedure time, and early recovery. Although EVAR seems to be an attractive solution with many advantages for AAA repair, there are detailed requirements and many important aspects should be understood before the procedure. In this comprehensive review, fundamental information regarding AAA and EVAR is presented.

Outcomes of Elective Endovascular Aneurysmal Repair for Abdominal Aortic Aneurysms in Jordan

Purpose

The outcomes of endovascular aneurysmal repair (EVAR) for infrarenal abdominal aortic aneurysms (AAAs) in the Middle East have rarely been reported. We analyzed the outcomes of EVAR in a Jordanian population.

Materials and Methods

We conducted a retrospective review of the medical records of patients with infrarenal AAA who were treated with elective EVAR between January 2004 and January 2017 at a single center in Jordan. Patient characteristics, anatomical characteristics, procedural details, and early and late postoperative outcomes were analyzed.

Results

A total of 288 patients (mean age, 70 years; 77.8% males) underwent EVAR for infrarenal AAA (median aneurysm size, 64 mm). Bifurcated endografts were used in 265 patients, and aorto-uni-iliac devices were used in 22 patients. Successful endograft deployment was achieved in all patients with no open conversion. Early complications included localized groin hematoma in 15, femoral artery dissection in 4, wound infection in 3, and seroma in 3 patients. With a mean follow-up of 60 months, 50 endoleaks were detected, including 9 type I, 38 type II, and 3 type III. Seven patients had unilateral graft limb occlusion. The 30-day mortality was 1.7%, and long-term mortality was 7.0%, mostly due to non-AAA-related causes.

Conclusion

EVAR was safely performed in Jordanian patients with minimal complications. However, long-term surveillance is important due to the risk of endoleaks and consequent intervention.

Pharmacological inhibition of Notch signaling regresses pre-established abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) is characterized by transmural infiltration of myeloid cells at the vascular injury site. Previously, we reported preventive effects of Notch deficiency on the development of AAA by reduction of infiltrating myeloid cells. In this study, we examined if Notch inhibition attenuates the progression of pre-established AAA and potential implications. Pharmacological Notch inhibitor (N-[N-(3,5-difluorophenacetyl)-L-alanyl]-(S)-phenylglycine t-butyl ester; DAPT) was administered subcutaneously three times a week starting at day 28 of angiotensin II (AngII) infusion. Progressive increase in pulse wave velocity (PWV), maximal intra-luminal diameter (MILD) and maximal external aortic diameter (MEAD) were observed at day 56 of the AngII. DAPT prevented such increase in MILD, PWV and MEAD (P < 0.01). Histologically, the aortae of DAPT-treated Apoe-/- mice had significant reduction in inflammatory response and elastin fragmentation. Naked collagen microfibrils and weaker banded structure observed in the aortae of Apoe-/- mice in response to AngII, were substantially diminished by DAPT. A significant decrease in the proteolytic activity in the aneurysmal tissues and vascular smooth muscle cells (vSMCs) was observed with DAPT (P < 0.01). In human and mouse AAA tissues, increased immunoreactivity of activated Notch signaling correlated strongly with CD38 expression (R2 = 0.61). Collectively, we propose inhibition of Notch signaling as a potential therapeutic target for AAA progression.

Investigation of an Immunogenetic Profile in Patients with Abdominal Aortic Aneurysms and Possible Applications in Screening and Surveillance

BACKGROUND

The pathogenesis of atherosclerotic abdominal aortic aneurysms (AAAs) remains not fully understood. Histological analyses confirm chronic adventitial and medial inflammatory cell infiltration, and its pathophysiology involves the upregulation of proteolytic pathways; added to this, genetic factors have been suggested to favor the susceptibility for AAA. The aim of the present study was to analyze the association between genetic polymorphism of the class II human leukocyte antigens (HLAs, HLA-DRB1) with the susceptibility to develop AAA in Mexican patients and to initiate a pilot study of single-nucleotide polymorphisms (SNPs) rs1024611 in the monocyte chemoattractant protein-1 (MCP-1/CCL2) gene to investigate a possible role in the AAA pathogenesis.

METHODS

In a cohort of patients with AAA, HLA molecular typing was completed for DRB1 loci with LABType SSO-One Lambda kit in 39 patients (69% men with a mean age of 72 years) and compared with 99 without the disease (60% men, mean age 65 years) (control group). Genotyping of rs1024611 in the MCP-1 gene was performed using TaqMan predesigned SNP genotyping assays in 27 patients with AAA (63% men, mean age of 71). Gene frequencies (gfs) and genotype frequencies (Gfs) were determined; categorical data were analyzed by nonparametric statistic test at significance level (P < 0.05), and odds ratios (ORs) were calculated using the STATA v14 software and StatCalc software Epi Info™ 7.2.2.2.

RESULTS

Seventy-eight HLA-DRB1 alleles of patients with AAA and 198 from the control group were studied. We observed that the gf of HLA-DRB1*01 was 0.128 in the AAA group compared with 0.05 in the control group (P = 0.03, OR: 2.6, 95% confidence interval [CI]: 1.04-6.5); the gf of HLA-DRB1*16 was 0.115 in the AAA and 0.025 in control group (P = 0.002, OR: 5, 95% CI: 1.6-16.9). The Gf for SNP rs1024611 were 0.51 in the GA genotype, 0.30 in AA, and 0.19 of GG. Four patients with the proinflammatory homozygous genotype GG (80%) were women and younger than patients with other genotypes, and only one had a history of dyslipidemia.

CONCLUSIONS

The dissection and interpretation of an immunogenetic profile in patients with AAA is an active and complex field of research that might assist in a more precise identification of those patients at genetic risk. Our study demonstrated increased frequencies of HLA-DRB1*01 and HLA-DRB1*16 alleles in Mexican patients with AAA compared with an ethnically matched control group.

Genetic polymorphism of HLA-DRB1 alleles in Mexican mestizo patients with abdominal aortic aneurysms

BACKGROUND

Multiple factors are implicated in the etiology and pathogenesis of Abdominal Aortic Aneurysms (AAA). Available literature of genetic studies has previously suggested the possible roles of autoimmunity, genetic predisposition and ethnic susceptibility. Due to the association with autoimmune diseases and proven application in population genetics, we aimed to investigate alleles of the Class II Human Leukocyte Antigens (HLA-DRB1) in the Mexican Mestizo population with aortic aneurysms and determine possible associations with susceptibility.

METHODS

We performed a case Control Study; the HLA molecular typing was completed for DRB1 loci by LabType Sequence-Specific Oligonucleotide (SSO) SSO-OneLambda kit (Applied Biosystems; Thermo Fisher Scientific. Inc.) in the studied individuals. Allele frequencies (af) were determined, associations were assessed by chi square or fisher exact tests at significance level (< 0.05), and Odds Ratios (OR) were calculated using the STATA software version 14.

RESULTS

The genetic polymorphism of HLA-DRB1 of fifty one patients (70% males with a mean age of 71 years) with atherosclerotic or also known as degenerative AAA were compared with 99 unrelated patients (60% males, mean age 65 years) without the disease [Control group (CG)] from the same ethnic group. We examined a total of 102 Class II HLA-DRB1 alleles of AAA patients and 198 from CG. When comparing af, we observed the HLA-DRB1*01 af of 0.139 in the AAA compared to 0.05 in the CG [p = 0.015, OR 3, 95% confidence interval (CI) 1.29-7.08], the HLA-DRB1*16 af were 0.109 in the AAA and 0.025 in CG (p = 0.006, OR 4.7, 95% CI 1.59-13.98).

CONCLUSIONS

Our study confirmed increased frequencies of the alleles HLA-DRB1*01 and HLA-DRB1*16 and their association to the development of AAA in Mexican Mestizo patients. The utility of genetic testing may assist in identifying individuals at genetic risk for the development of this disease in different ethnic groups, who might benefit from earlier ultrasound screening and closer imaging surveillance.

AGD: Aneurysm Gene Database

An aneurysm is an outward bulge on an arterial wall. Aneurysms are becoming a serious public health concern as the worldwide population ages. Unfortunately, no effective drugs have been developed for aneurysms to date. In addition, aneurysms may be associated with grave prognosis due to conditions such as ruptures and recurrence. Altogether, these factors make earlier aneurysm prevention, diagnosis and intervention strategies even more important. A bioinformatics resource for aneurysm-associated molecules would be helpful for addressing the above issues; however, such a tool is not yet available. In this study, we developed Aneurysm Gene Database (AGD) for the above purpose. AGD contains 1472 aneurysm-gene associations, including 29 types of aneurysms, 967 protein-coding genes, 29 miRNAs, 6 lncRNAs and several other types of molecules. Users can search, browse and download content in AGD. We believe that AGD is a valuable resource that can help us better understand aneurysms and discover novel treatment targets.