Funding, Deals & Partnerships: BIOLOGICS & MEDICAL DEVICES; BioMed e-Series; Medicine and Life Sciences Scientific Journal – http://PharmaceuticalIntelligence.com
From the Molecular and Cellular Pharmacology Graduate Program (T.D., J.Y.) and Department of Anesthesiology (M.W., J.Y.), University of Wisconsin School of Medicine and Public Health, Madison; Illumavista Biosciences LLC, Madison, WI (C.L.W.); and Biomedical Informatics Research Center, Marshfield Clinics Research Foundation, Marshfield, WI (P.P.).
Correspondence to Jay Yang, MD, PhD, Department of Anesthesiology, University of Wisconsin SMPH, SMI 301, 1300 University Ave, Madison, WI 53706. E-mailJyang75@wisc.edu
Abstract
Background—Degradation of extracellular matrix support in the large abdominal arteries contribute to abnormal dilation of aorta, leading to abdominal aortic aneurysms, and matrix metalloproteinase-9 (MMP-9) is the predominant enzyme targeting elastin and collagen present in the walls of the abdominal aorta. Previous studies have suggested a potential association between MMP-9 genotype and abdominal aortic aneurysm, but these studies have been limited only to the p-1562 and (CA) dinucleotide repeat microsatellite polymorphisms in the promoter region of the MMP-9 gene. We determined the functional alterations caused by 15 MMP-9 single-nucleotide polymorphisms (SNPs) reported to be relatively abundant in the human genome through Western blots, gelatinase, and promoter–reporter assays and incorporated this information to perform a logistic-regression analysis of MMP-9 SNPs in 336 human abdominal aortic aneurysm cases and controls.
Methods and Results—Significant functional alterations were observed for 6 exon SNPs and 4 promoter SNPs. Genotype analysis of frequency-matched (age, sex, history of hypertension, hypercholesterolemia, and smoking) cases and controls revealed significant genetic heterogeneity exceeding 20% observed for 6 SNPs in our population of mostly white subjects from Northern Wisconsin. A step-wise logistic-regression analysis with 6 functional SNPs, where weakly contributing confounds were eliminated using Akaike information criteria, gave a final 2 SNP (D165N and p-2502) model with an overall odds ratio of 2.45 (95% confidence interval, 1.06–5.70).
Conclusions—The combined approach of direct experimental confirmation of the functional alterations of MMP-9 SNPs and logistic-regression analysis revealed significant association between MMP-9 genotype and abdominal aortic aneurysm.
Open Abdominal Aortic Aneurysm (AAA) repair (OAR) vs. Endovascular AAA Repair (EVAR) in Chronic Kidney Disease (CKD) Patients – Comparison of Surgery Outcomes
Writer and Curator: Larry H. Bernstein, MD, FCAP
and
Curator: Aviva Lev-Ari, PhD, RN
This is a review of the effects of CKD on increased morbidity and mortality of abdominal aortic aneurysm repair. The abdominal aorta has branches to the superior mesenteric arteries proximally, and below that both renal arteries, which also supply the adrenals (suprarenal).
Severe atherosclerosis with plaque buildup and separation of the media from the endothelium, can migrate down the addominal aorta before frank rupture of an aneurysm. Abdominal aortic aneurysm often extends from below the the renal arteries, to the internal spermatic vessels, or as far as the iliacs.
Of the visceral branches, the celiac artery and the superior and inferior mesenteric arteries are unpaired, while the suprarenals, renals, internal spermatics, and ovarian are paired. Of the parietal branches the inferior phrenics and lumbars are paired; the middle sacral is unpaired. The terminal branches are paired.
AAA is most common in men over age 65 years. If it is expanding AAA causes sudden, severe, and constant low back, flank, abdominal, or groin pain (internal spermatic branch). The presence of a pulsatile abdominal mass is virtually diagnostic but is found in less than half of all cases. At least 65% of patients with a ruptured AAA die from sudden cardiovascular collapse before arriving at a hospital.
A study by Mehta et al assessed the effect of hemodynamic status on outcomes in 136 patients undergoing EVAR for ruptured AAAs.[1] The patients were divided into 2 groups:
(1) Hd-stable (systolic BP ≥80 mm Hg; n = 92 [68%]) and
(2) Hd-unstable (systolic BP < 80 mm Hg for >10 minutes; n = 44 [32%]).
The 30-day mortality, postoperative complications, need for secondary reinterventions, and midterm mortality were recorded. The 2 groups were found to be similar with respect to
comorbidities,
mean AAA maximum diameter (6.6 vs 6.4 cm),
need for on-the-table conversion to open repair (3% vs 7%), and
incidence of nonfatal complications (43% vs 38%) and secondary interventions (23% vs 25%).
intraoperative need for aortic occlusion balloon,
mean estimated blood loss,
incidence of developing abdominal compartment syndrome (ACS), and
mortality
were all increased in the Hd-unstable group ([1]40% vs 6%, [2]744 vs 363 mL,[3] 29% vs 4%, and[4]33% vs 18%, respectively).
Requires direct access to the aorta through an abdominal or retroperitoneal approach
Endovascular: Involves gaining access to the lumen of the abdominal aorta, usually via small incisions over the femoral vessels; an endograft, typically a cloth graft with a stent exoskeleton, is placed within the lumen of the AAA, extending distally into the iliac arteries. Approximately 90% of abdominal aortic aneurysms are infrarenal.
The important surgical and endovascular anatomic considerations include associated renal and visceral artery involvement (either occlusive disease or involved in the aneurysm process) and the iliac artery (either occlusive disease or aneurysms). The length of the infrarenal aortic neck is important in helping determine the surgical approach (retroperitoneal vs transabdominal) and the location of the aortic cross clamp.
Endovascular repair first became practical in the 1990s and although it is now an established alternative to open repair, its role is yet to be clearly defined. It is generally indicated in older, high-risk patients or patients unfit for open repair. However, endovascular repair is feasible for only a proportion of AAAs, depending on the morphology of the aneurysm. The main advantages over open repair are that there is less peri-operative mortality, less time in intensive care, less time in hospital overall and earlier return to normal activity. Disadvantages of endovascular repair include a requirement for more frequent ongoing hospital reviews, and a higher chance of further procedures being required. According to the latest studies, the EVAR procedure does not offer any benefit for overall survival or health-related quality of life compared to open surgery, although aneurysm-related mortality is lower.
The diameter of the aorta decreases in size from its thoracic portion to the abdominal and infrarenal portions. A normal aorta shows a reduction in medial elastin layers from the thoracic area to the abdominal portion. Elastin and collagen content are also reduced. AAAs develop following degeneration of the media. The degeneration ultimately may lead to widening of the vessel lumen and loss of structural integrity.
A multidisciplinary research program supported by the US National Heart, Lung, and Blood Institute identified proteolytic degradation of aortic wall connective tissue, inflammation and immune responses, biomechanical wall stress, and molecular genetics as mechanisms important in the development of AAA. Similarly, surgical specimens of AAA reveal inflammation, with infiltration by lymphocytes and macrophages; thinning of the media; and marked loss of elastin.
Through gene microarray analysis, various genes involved in extracellular matrix degradation, inflammation, and other processes observed in AAA formation have been shown to be up-regulated, while others that may serve to prevent this occurrence are down-regulated. The combination of proteolytic degradation of aortic wall connective tissue, inflammation and immune responses, biomechanical wall stress, and molecular genetics represents a dynamic process that leads to aneurysmal deterioration of aortic tissue.
1. Mehta M, Paty PS, Byrne J, Roddy SP, Taggert JB, Sternbach Y, et al. The impact of hemodynamic status on outcomes of endovascular abdominal aortic aneurysm repair for rupture. J Vasc Surg. May 2013;57(5):1255-60. [Medline].
2. Blanchard JF, Armenian HK, Friesen PP. Risk factors for abdominal aortic aneurysm: results of a case-control study. Am J Epidemiol. Mar 15 2000;151(6):575-83. [Medline].
3. Lederle FA, Johnson GR, Wilson SE, Chute EP, Littooy FN, Bandyk D, et al. Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med. Mar 15 1997;126(6):441-9. [Medline].
4. Wassef M, Baxter BT, Chisholm RL, Dalman RL, Fillinger MF, Heinecke J, et al. Pathogenesis of abdominal aortic aneurysms: a multidisciplinary research program supported by the National Heart, Lung, and Blood Institute. J Vasc Surg. Oct 2001;34(4):730-8. [Medline].
5. [Guideline] U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med. Feb 1 2005;142(3):198-202. [Medline]. [Full Text].
Impact of chronic kidney disease on outcomes after abdominal aortic aneurysm repair
Chronic kidney disease (CKD) is associated with increased morbidity and death after open abdominal aortic aneurysm (AAA) repair (OAR). This study highlights the effect of CKD on outcomes after endovascular AAA (EVAR) and OAR in contemporary practice.
The National Surgical Quality Improvement Program (NSQIP) Participant Use File (2005-2008) was queried by Current Procedural Terminology (American Medical Association, Chicago, Ill) code to identify EVAR or OAR patients, who were grouped by CKD class as having mild (CKD class 1 or 2), moderate (CKD class 3), or severe (CKD class 4 or 5) renal disease. Propensity score analysis was performed to match OAR and EVAR patients with mild CKD with those with moderate or severe CKD. Comparative analysis of mortality and clinical outcomes was performed based on CKD strata.
We identified 8701 patients who were treated with EVAR (n = 5811) or OAR (n = 2890) of intact AAAs. Mild, moderate, and severe CKD was present in 63%, 30%, and 7%, respectively. CKD increased (P < .01) overall mortality, with rates of 1.7% (mild), 5.3% (moderate), and 7.7% (severe) in unmatched patients undergoing EVAR or OAR. Operative mortality rates in patients with severe CKD were as high as 6.2% for EVAR and 10.3% for OAR.
Severity of CKD was associated with increasing frequency of risk factors; therefore, propensity matching to control for comorbidities was performed, resulting in similar baseline clinical and demographic features of patients with mild compared with those with moderate or severe disease.
In propensity-matched cohorts, moderate CKD increased the risk of 30-day mortality
for EVAR (1.9% mild vs 3.2% moderate; P = .013) and
OAR (3.1% mild vs 8.4% moderate; P < .0001).
Moderate CKD was also associated with increased morbidity in patients treated with
EVAR (8.3% mild vs 12.8% moderate; P < .0001) or
OAR (25.2% mild vs 32.4% moderate; P = .001).
Similarly, severe CKD increased the risk of 30-day mortality
for EVAR (2.6% mild vs 5.7% severe; P = .0081) and
OAR (4.1% mild vs 9.9% severe; P = .0057).
Severe CKD was also associated with increased morbidity in patients treated with
EVAR (10.6% mild vs 19.2% severe; P < .0001) or
OAR (31.1% mild vs 39.6% severe; P = .04).
The presence of moderate or severe CKD in patients considered for AAA repair is associated with significantly increased mortality and therefore should figure prominently in clinical decision making. The high mortality of AAA repair in patients with severe CKD is such that elective repair in such patients is not advised, except in extenuating clinical circumstances.
Competition in the Ecosystem of Medical Devices in Cardiac and Vascular Repair: Heart Valves, Stents, Catheterization Tools and Kits for Open Heart and Minimally Invasive Surgery (MIS)
Acute and Chronic Myocardial Infarction: Quantification of Myocardial Perfusion Viability – FDG-PET/MRI vs. MRI or PET alone (Justin Pearlman, Aviva Lev-Ari)
Carotid Stenting: Vascular surgeons have pointed to more minor strokes in the stenting group and cardiologists to more myocardial infarctions in the CEA cohort.
Global Supplier Strategy for Market Penetration & Partnership Options (Niche Suppliers vs. National Leaders) in the Massachusetts Cardiology & Vascular Surgery Tools and Devices Market for Cardiac Operating Rooms and Angioplasty Suites
Abdominal Aortic Aneurysms (AAA): Albert Einstein’s Operation by Dr. Nissen
Reporter: Aviva Lev-Ari, PhD, RN
On June 11, 2013, I received the following comment by Dr. Miranda, to my article, an Interview with Dr. Richard Cambria, Chief Vascular Surgery, MGH, Boston
Efrain Miranda, Ph.D. • It is true that abdominal aortic aneurysms (AAA) are mostly asymptomatic, until they rupture. By luck, some are identified. An example was a AAA found in Albert Einstein by Dr. Nissen when Einstein went for abdominal surgery for something completely unrelated! In my experience, I have found many AAA’s in individuals who had a totally different cause of death. http://clinanat.com/mtd/153-aneurysm
I am presenting here the the CASE of an AAA found in Albert Einstein by Dr. Nissen when Einstein went for abdominal surgery for something completely unrelated!
A Moment in History
Dr. Rudolf Nissen
(1896 – 1981)
Dr Nissen’s life is extraordinary. Born in the city of Neisse, Germany in 1896, he was the son of a local surgeon. He studied medicine in the Universities of Munich, Marburg, and Breslau. He was the pupil of the famous pathologist Albert Aschoff (discoverer of the heart’s AV node, along with Sunao Tawara).
Nissen became a professor of surgery in Berlin, and in 1933 moved to Turkey where he was placed in charge of the Department of Surgery of the University of Istanbul. In 1939 he moved to the US, first to the Massachusetts General Hospital and later to the Jewish Hospital in Brooklyn, New York. After becoming a US citizen, he moved again in 1952 to Basel, Switzerland as Chief of the Department of Surgery, where he retired in 1967. He died in 1981.
His contributions to surgery are innumerable. He wrote over 30 books and 450 journal articles. Known for the development in 1956 of what is today known as the “Nissen fundoplication” for esophageal hiatus hernia surgery, Nissen also worked with his assistant, Dr. Mario Rossetti to develop the “floppy Nissen fundoplication”, also known as the “Nissen-Rossetti procedure”. This would be enough to honor this man, still, he (with Sauerbruch) performed the first lung lobectomy and the first pneumonectomy (called then a total pneumonectomy). In 1949 he performed the first esophagectomy with a gastroesophagostomy.
His personal life is even more interesting. Drafted at 20, he fought in WWI and was wounded several times. In 1933, under the Nazi regime, he was ordered to fire all the Jewish-German assistants under his care. Being Jewish himself, he was told that he would keep his job, Nissen could not take this. He resigned his position and moved out of Germany.
Another little known fact is that he operated on Albert Einstein in 1948. He operated on Einstein because of intestinal cysts. Having found a developing abdominal aortic aneurysm, he reinforced it with cellophane, undoubtedly giving his patient a few extra years to live. Einstein died in 1955.
As a personal side note, our good friend Dr. Aaron Ruhalter scrubbed in with Dr. Nissen while serving as a surgical resident at the Brooklyn Jewish Hospital!
I shadowed Dr. Cambria in the Operating Room at MGH in January 2005 while he performed Carotid EndarterectomyfollowingAortic Valve Replacement performed by Dr. Jennifer D. Walker in a sequence, first the Valve replacement, then the Endarterectomy.
This word has a Greek origin from the terms [aneurusma], composed of [ana] meaning “complete or throughout”, and [eurus] meaning “wide”, a “complete widening or dilation”. It is used to refer to the dilation of an artery. Aneurysms can be formed in any artery, although they have some preferred sites. The most common aneurysms are found in the aorta, arterial circle of Willis, the root of the cerebral arteries, and internal carotid arteries.Biomechanical studies suggest that once an aneurysm forms it will generally progress in its dilation until aneurysmal rupture. Because of turbulent flow within the aneurysm large clots are usually formed, which in turn can cause emboli.The image shows an excised infrarenal aortic abdominal aneurysm (AAA). The two common iliac arteries can be seen. If you click on the image you will be able to see the same aneurysm opened through its posterior wall and the clot that was contained inside.Photography by D.M.Klein
It is true that abdominal aortic aneurysms (AAA) are mostly asymptomatic, until they rupture. By luck, some are identified. An example was a AAA found in Albert Einstein by Dr. Nissen when Einstein went for abdominal surgery for something completely unrelated! In my experience, I have found many AAA’s in individuals who had a totally different cause of death.
Dr. Richard Cambria describes an Aortic Aneurysm and recalls the numerous risk factors associated with the condition.
Dr. Cambria:
An aortic aneurysm can be most simply thoughts of as a weakening or ballooning of the aorta which is the body’s major and largest blood vessel. That’s important because this ballooning or weakening can eventually lead to the aneurysm bursting, which is usually a fatal event.
Aneurysms have been referred to as the ‘silent killer’ because in most cases these aortic aneurysms cause no symptoms or problems prior to bursting. Most aortic aneurysms occur in older patients, but there are a clearly defined set of risk factors which makes certain patients at higher risk of developing aortic aneurysms. These include, most importantly, a family history of aortic aneurysm disease, and by family history I mean, if your mother or father or a brother or sister had an aortic aneurysm, you are clearly at increased risk of developing an aneurysm.
20% of the patients that we treat for aortic aneurysms have a positive family history of aneurysm disease. You are also at higher risk for developing an aortic aneurysm if you are female, if you have a history of high blood pressure, if you have been a cigarette smoker, and if you have chronic obstructive pulmonary disease or emphysema, which is in turn related to long-term cigarette smoking.
If you are at risk for developing an aortic aneurysm there are simple diagnostic x-ray studies such as ultrasounds and CAT scans to accurately diagnose number one, whether or not an aneurysm is present, and more importantly, if it is present, to measure just how large it is because that’s the single most important factor in determining whether or not your aneurysm needs to be treated.
It’s important to detect and monitor aortic aneurysms before they reach the stage of bursting because treatment is then usually successful with an expected excellent recovery. Treatment of aortic aneurysms today is very effective and involves replacing the aneurysm with an artificial blood vessel.
There are a variety of different surgical treatments, some of them including minimally invasive operations known as stent grafts, which are applied today in many patients.
Mass General has been a leader in the northeast in the successful management of aortic aneurysms. More than a decade ago, we formed the Mass General Thoracic Aortic Center, which is a team-approach of vascular surgeons, cardiac or heart surgeons, and cardiologists to effectively manage thoracic aneurysms which are often the most challenging and clinically complex to treat.
About Dr. Richard Paul Cambria, M.D.:
Richard P. Cambria, M.D. is Professor of Surgery at Harvard Medical School and Chief, Division of Vascular/Endovascular Surgery at Massachusetts General Hospital. Dr. Cambria received his medical degree from the College of Physicians and Surgeons, Columbia University, in 1977. He trained in general and vascular surgery at Massachusetts General Hospital.
Giant Cell Aortitis of the Ascending Aorta Without Signs or Symptoms of Systemic Vasculitis is Associated with Elevated Risk of Distal Aortic Events.
Date
February 2012
Journal
Arthritis and Rheumatism
Title
Long-term Outcomes of Patients Undergoing Endovascular Infrainguinal Interventions with Single-vessel Peroneal Artery Runoff.
Date
May 2011
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
The Effects of Systemic Hypothermia on a Murine Model of Thoracic Aortic Ischemia Reperfusion.
Date
August 2010
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Long-term Outcomes of Diabetic Patients Undergoing Endovascular Infrainguinal Interventions.
Date
August 2010
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Preoperative Variables Predict Persistent Type 2 Endoleak After Endovascular Aneurysm Repair.
Date
August 2010
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Surgical Management of Descending Thoracic Aortic Disease: Open and Endovascular Approaches: a Scientific Statement from the American Heart Association.
Date
August 2010
Journal
Circulation
Title
Balloon Expandable Stents Facilitate Right Renal Artery Reconstruction During Complex Open Aortic Aneurysm Repair.
Date
March 2010
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Preoperative Functional Status Predicts Perioperative Outcomes After Infrainguinal Bypass Surgery.
Date
March 2010
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Intermediate-term Outcomes of Endovascular Treatment for Symptomatic Chronic Mesenteric Ischemia.
Date
February 2010
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
A Multicenter Clinical Trial of Endovascular Stent Graft Repair of Acute Catastrophes of the Descending Thoracic Aorta.
Date
December 2009
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Aortic Remodeling After Endovascular Repair of Acute Complicated Type B Aortic Dissection.
Date
September 2009
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Thoracoabdominal Aneurysm Repair: Hybrid Versus Open Repair.
Date
July 2009
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Successful Use of Bivalirudin for Combined Carotid Endarterectomy and Coronary Revascularization with the Use of Cardiopulmonary Bypass in a Patient with an Elevated Heparin-platelet Factor 4 Antibody Titer.
Functional Outcome After Thoracoabdominal Aneurysm Repair.
Date
December 2008
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Outcomes Following Endovascular Abdominal Aortic Aneurysm Repair (evar): an Anatomic and Device-specific Analysis.
Date
August 2008
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Spinal Cord Complications After Thoracic Aortic Surgery: Long-term Survival and Functional Status Varies with Deficit Severity.
Date
August 2008
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Five-year Results of Endovascular Treatment with the Gore Tag Device Compared with Open Repair of Thoracic Aortic Aneurysms.
Date
June 2008
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Journal of the American College of Radiology : Jacr
Title
International Controlled Clinical Trial of Thoracic Endovascular Aneurysm Repair with the Zenith Tx2 Endovascular Graft: 1-year Results.
Date
March 2008
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Long-term Durability of Open Abdominal Aortic Aneurysm Repair.
Date
November 2007
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Commentary On: Mas Jl, Chatellier G, Beyssen B, Et Al. Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis. N Engl J Med. 2006;355:1660-1671.
Date
November 2007
Journal
Perspectives in Vascular Surgery and Endovascular Therapy
Defining the High-risk Patient for Carotid Endarterectomy: an Analysis of the Prospective National Surgical Quality Improvement Program Database.
Date
October 2007
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Persistent Type 2 Endoleak After Endovascular Repair of Abdominal Aortic Aneurysm is Associated with Adverse Late Outcomes.
Date
July 2007
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Restenosis After Eversion Vs Patch Closure Carotid Endarterectomy.
Date
July 2007
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Surgical Revascularization Versus Endovascular Therapy for Chronic Mesenteric Ischemia: a Comparative Experience.
Date
July 2007
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Comparison of Risk-adjusted 30-day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Men.
Stent-graft Versus Open-surgical Repair of the Thoracic Aorta: Mid-term Results.
Date
January 2007
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Intermediate Results of Percutaneous Endovascular Therapy of Femoropopliteal Occlusive Disease: a Contemporary Series.
Date
October 2006
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Commentary on “extra-anatomic Visceral Revascularization and Endovascular Stent-grafting for Complex Thoracoabdominal Aortic Lesions”.
Date
May 2006
Journal
Perspectives in Vascular Surgery and Endovascular Therapy
Title
Multi-institutional Pivotal Trial of the Zenith Tx2 Thoracic Aortic Stent-graft for Treatment of Descending Thoracic Aortic Aneurysms: Clinical Study Design.
Date
May 2006
Journal
Perspectives in Vascular Surgery and Endovascular Therapy
Aortic Dissection: Perspectives in the Era of Stent-graft Repair.
Date
March 2006
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Title
Current Results of Open Surgical Repair of Descending Thoracic Aortic Aneurysms.
Date
March 2006
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Title
Late Results of Combined Carotid and Coronary Surgery Using Actual Versus Actuarial Methodology.
Contemporary Results of Angioplasty-based Infrainguinal Percutaneous Interventions.
Date
November 2005
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Safety and Efficacy of Reoperative Carotid Endarterectomy: a 14-year Experience.
Date
July 2005
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Determinants of Carotid Endarterectomy Anatomic Durability: Effects of Serum Lipids and Lipid-lowering Drugs.
Date
May 2005
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Early Outcomes of Endovascular Versus Open Abdominal Aortic Aneurysm Repair in the National Surgical Quality Improvement Program-private Sector (nsqip-ps).
Date
May 2005
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Endovascular Treatment of Thoracic Aortic Aneurysms: Results of the Phase Ii Multicenter Trial of the Gore Tag Thoracic Endoprosthesis.
Date
March 2005
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Preservation of Renal Function with Surgical Revascularization in Patients with Atherosclerotic Renovascular Disease.
Date
February 2004
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Durability of Aortouniiliac Endografting with Femorofemoral Crossover: 4-year Experience in the Evt/guidant Trials.
Date
June 2003
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Late Aortic and Graft-related Events After Thoracoabdominal Aneurysm Repair.
Date
February 2003
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Evolving Experience with Thoracic Aortic Stent Graft Repair.
Date
July 2002
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Clinical Failures of Endovascular Abdominal Aortic Aneurysm Repair: Incidence, Causes, and Management.
Date
July 2002
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Regarding “analysis of Predictive Factors for Progression of Type B Aortic Intramural Hematoma with Computed Tomography”.
Date
July 2002
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Title
Contemporary Management of Aortic Branch Compromise Resulting from Acute Aortic Dissection.
Date
July 2001
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Endovascular Repair of Abdominal Aortic Aneurysms: Current Status and Future Directions.
Date
August 2000
Journal
Ajr. American Journal of Roentgenology
Title
Epidural Cooling for Spinal Cord Protection During Thoracoabdominal Aneurysm Repair: A Five-year Experience.
Date
July 2000
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Utility and Reliability of Endovascular Aortouniiliac with Femorofemoral Crossover Graft for Aortoiliac Aneurysmal Disease.
Date
July 2000
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Surgical Renal Artery Reconstruction Without Contrast Arteriography: the Role of Clinical Profiling and Magnetic Resonance Angiography.
Date
January 2000
Journal
Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Cambria RP, Brewster DC, Lauterbach SR, Kaufman JA, Geller SC, Fan CM, Greenfield A, Hilgenberg A, Clouse WD. Evolving experience with thoracic aortic stent-graft repair. J Vasc Surg 2002:35:1129-36.
Cambria, RP, Clouse WD, Davison JK, Dunn PF, Corey M, Dorer D. Thoracoabdominal aneurysm repair: Results with 337 operations performed over a 15 year interval. Ann Surg 2002;236-471-79.
Cambria RP and Black JH. Aortic dissection perspectives for the vascular/endovascular surgeon. In Rutherford (ed) Comprehensive Vascular and Endovascular Surgery 6 th , W. B. Saunders, Inc. (in press, 2004).
Cambria RP, Marone LK, Cloud WD, Dorer, DJ, Brewster, DC, LaMuraglia, GM, Watkins, MT, Kwolek, CJ. Preservation of renal functions with surgical revascularization in patients with atherosclerotic renovascular disease. J Vasc Surg 2004; 10.023.
An aneurysm is defined as a focally dilated segment of an artery that is 1.5 times its normal diameter and involves all three arterial walls (intima, media and adventitia). Aneurysms can be found in the common femoral and popliteal arteries in the lower extremities, the splenic, mesenteric, and renal arteries in the abdomen, and also in the intracranial vessels. However, the most common is an abdominal aortic aneurysm (AAA) involving the aorta and iliac arteries.
Abdominal aortic aneurysms are generally asymptomatic and are discovered accidentally either by physician palpation or by a radiologic examination such as a chest or abdominal X-ray. The risk factors that increase the probability of developing a AAA are primarily smoking and family history. An abdominal aortic aneurysm can rupture and, according to the Centers for Disease Control and Prevention, ruptured AAA was the 10th leading cause of death in males between the ages of 65-74 in the United States in 2000.
The preferred method of screening for AAA is diagnostic ultrasound. According to the Journal of Vascular Surgery, diagnostic ultrasound performed by a registered vascular technologist has a sensitivity of 100 percent and a specificity of 96 percent for the detection of an infrarenal AAA. The abdominal aorta is considered aneurysmal when it measures >3.0 cm.
Because of its accuracy, diagnostic ultrasound not only has become an integral part in diagnosing AAA but is also an integral part in the evaluation of disease progression, the preoperative AAA evaluation, and the follow-up of AAA surgical repair. It is important to note that a rupture of an AAA is a surgical emergency and is difficult to evaluate with ultrasound due to the inability to easily demonstrate abdominal free fluid. If a rupture is suspected, it is recommended that other imaging modalities such as CT be employed to better demonstrate the ruptured aneurysm and any intra-abdominal free fluid.
Case Study –
Abdominal Aortic Aneurysm – A 77 year-old male
Angela Rodriguez-Wong, MD, RVT, RPVI
Lois Eliassi, BS, RVT
Figure 1 Distal abdominal aortic aneurysm with mural thrombus.
Figure 2 Bifurcation of the aorta.
Case Study: A 77 year-old male with a past medical history of diabetes, hypertension, arthritis, aortic valve disease and heavy smoking was referred to Eastern Vascular Diagnostic Center with a 4.2 centimeter aneurysm. The patient denied any family history of aneurysm and is allergic to intravenous contrast. A physical exam found the patient alert with a blood pressure of 100/60 mmHg, a pulse of 58 and respiration of 16. Auscultation found a bruit in the left carotid artery, clear lungs, and a regular heart rhythm with an aortic systolic murmur. The patient had a well healed sub-costal incision on his abdomen. The physician was unable to palpate the aneurysms. The patient had an aortic valve replacement in 2007 and also a cholecystectomy. On May 12, 2012, a magnetic resonance imaging (MRI) scan without contrast was performed on the patient’s abdomen. The MRI found an AAA measuring greater than 3 cm with extensive plaque near the bifurcation. The aneurysm extended into the right common iliac artery (CIA) measuring 4.2 cm and into the left CIA measuring 3.1 cm. The MRI exam did not include the pelvis, so the extent of the iliac aneurysms was not clear. On July 31, 2012, the ultrasound was performed, demonstrating normal ankle brachial index (right-1.2, left-1.1) and a AAA measuring 3.9 cm which extended into the right and left CIA. The maximum diameter of the right CIA measures 4.1 cm with mural thrombus creating a residual lumen of 2.0 cm. The maximum diameter of the left CIA measures 4.3 cm, there is also mural thrombus noted but without significant appreciable diameter reduction within the vessel. A computed tomography (CT) scan of the abdomen and pelvis without contrast was performed on July 18th confirming the infrarenal AAA with extension into the iliac arteries bilaterally.
Surgery is recommended when an AAA reaches 5.0-5.5 cm in a male and 4.5-5.0 cm in females. Surgery, depending on the aneurysm, can be an open repair or an endovascular repair. In this patient, despite the size of the AAA being 4.1 cm, the disease also involved the bilateral common iliacs prompting the need for surgical intervention. The patient was cleared by cardiology and on July 31st had an AAA and bilateral Iliac aneurysm resection with a re-implantation of the inferior mesenteric artery and an Aorta to right Hypogastric bypass to maintain pelvic perfusion.
The U.S. Preventive Services Task Force has released a statement summarizing recommendations for screening for AAA. It states that screening benefits patients who have a relatively high risk for dying from an aneurysm; major risk factors are age 65 years or older, male sex, and smoking at least 100 cigarettes in a lifetime. The guideline recommends one-time screening with ultrasound for AAA in men 65 to 75 years of age who have ever smoked. No recommendation was made for or against screening in men 65 to 75 years of age who have never smoked, and it recommended against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age.
Angela Rodriguez-Wong, MD, RVT, RPVI
awong@navixdiagnostix.com
Lois Eliassi, BS, RVT
leliassi@navixdiagnostix.com
Figure 3 Sagittal image of the right common iliac artery demonstrating the measurement of the aneurysm and the true lumen.
Figure 4 Coronal view of the left common iliac artery.
Abdominal Aortic Aneurysm: Endovascular repair and open repair resulted in similar long-term survival
Reporter: Aviva Lev-Ari, PhD, RN
Long-Term Comparison of Endovascular and Open Repair of Abdominal Aortic Aneurysm
Frank A. Lederle, M.D., Julie A. Freischlag, M.D., Tassos C. Kyriakides, Ph.D., Jon S. Matsumura, M.D., Frank T. Padberg, Jr., M.D., Ted R. Kohler, M.D., Panagiotis Kougias, M.D., Jessie M. Jean-Claude, M.D., Dolores F. Cikrit, M.D., and Kathleen M. Swanson, M.S., R.Ph. for the OVER Veterans Affairs Cooperative Study Group
We randomly assigned 881 patients with asymptomatic abdominal aortic aneurysms who were candidates for both procedures to either endovascular repair (444) or open repair (437) and followed them for up to 9 years (mean, 5.2). Patients were selected from 42 Veterans Affairs medical centers and were 49 years of age or older at the time of registration.
RESULTS
More than 95% of the patients underwent the assigned repair. For the primary outcome of all-cause mortality, 146 deaths occurred in each group (hazard ratio with endovascular repair versus open repair, 0.97; 95% confidence interval [CI], 0.77 to 1.22; P=0.81). The previously reported reduction in perioperative mortality with endovascular repair was sustained at 2 years (hazard ratio, 0.63; 95% CI, 0.40 to 0.98; P=0.04) and at 3 years (hazard ratio, 0.72; 95% CI, 0.51 to 1.00; P=0.05) but not thereafter. There were 10 aneurysm-related deaths in the endovascular-repair group (2.3%) versus 16 in the open-repair group (3.7%) (P=0.22). Six aneurysm ruptures were confirmed in the endovascular-repair group versus none in the open-repair group (P=0.03). A significant interaction was observed between age and type of treatment (P=0.006); survival was increased among patients under 70 years of age in the endovascular-repair group but tended to be better among those 70 years of age or older in the open-repair group.
CONCLUSIONS
Endovascular repair and open repair resulted in similar long-term survival. The perioperative survival advantage with endovascular repair was sustained for several years, but rupture after repair remained a concern. Endovascular repair led to increased long-term survival among younger patients but not among older patients, for whom a greater benefit from the endovascular approach had been expected. (Funded by the Department of Veterans Affairs Office of Research and Development; OVER ClinicalTrials.gov number,NCT00094575.)
Supported by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
SOURCE INFORMATION
From the Veterans Affairs Medical Centers in Minneapolis (F.A.L.), Baltimore (J.A.F.), West Haven, CT (T.C.K.), Madison, WI (J.S.M.), East Orange, NJ (F.T.P.), Seattle (T.R.K.), Houston (P.K.), Cleveland (J.M.J.-C.), Indianapolis (D.F.C.), and Albuquerque, NM (K.M.S.).
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