Search

Objective: The aim of this study was to report the clinical presentation and treatment outcomes of patients treated for IAAD with and without abdominal aortic aneurysm (AAA) in a single academic institution in South America., Materials and Methods: A retrospective review of all patients with IAAD with or without concomitant AAA between January 2002 and December 2023 from a single academic hospital was performed., Results: Eighteen patients with IAAD were diagnosed of whom 13 (72.2%) were males. Median age was 63 years (range: 43-88 years). Sixteen (88.8%) patients presented with symptoms, and in two (11.1%) asymptomatic patients IAAD was an incidental finding. Ten (55.5%) patients had concomitant abdominal aortic aneurysm (AAA), with a median size of the aneurysm of 49.5 mm (range: 44-66 mm). No statistical differences in baseline characteristics were seen between patients with concomitant IAAD and AAA and patients with only IAAD. Seven (38.8%) patients presented chronic dissection, and 11 (61.1%) patients had acute dissection. Five (27.7%) patients were treated conservatively with blood pressure, pain control, and antiplatelets; endovascular surgery was performed in eight (44.4%) patients and open surgery in five (27.7%) patients. The complication rate was 22.2% (n = 4), and the mortality rate was 0%. Median follow-up was 36 months (range: 6-240 months). Complete remodeling was seen in all patients except two patients who underwent conservative treatment. Of those, one had partial remodeling, and the other no changed., Conclusion: Isolated aortic dissection of the abdominal aorta is an uncommon condition, with acceptable different treatment strategies, from conservative to invasive treatments. Sometimes IAAD can concur with AAA, and when so, invasive treatment might be considered. More studies describing the natural history of AAA and its association with IAAD are warranted, as well as further research reporting long-term outcomes on aortic remodeling after different treatment modalities., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Femoral artery aneurysms (FAAs) can occur in some patients with abdominal aortic aneurysms. There is a lack of natural history studies in the published literature. Guidelines recommend FAA repair when symptomatic or larger than 2.5 cm in diameter to prevent aneurysm-related complications. The presence of intraluminal thrombus may also be a risk factor for these complications as well. We present a case of a male in his 70s who underwent simultaneous endovascular aortic repair and repair of his left FAA with no complications after surgery. We propose that these patients may benefit from combined repair by performing these procedures together., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Conflict of interest: None declared.

Background and Objective: Misdiagnosis of ruptured abdominal aortic aneurysms (rAAA) contributes to delayed treatment and potentially higher mortality. The symptomatology in patients with rAAA is complex and challenging, 25-50% presumably fulfill the criteria of the standard triad of signs (STS). The objective was to determine the initial signs registered for patients with verified rAAAs, and to investigate if an expanded diagnostic triad could increase the diagnostic accuracy., Methods: A population-based study was conducted among all patients presenting with verified rAAAs in Stockholm County, Sweden, from January 2010 to October 2021. Patients were identified with ICD code 171.3 (rAAA). The STS was defined as (1) abdominal pain, (2) syncope and (3) the finding of a pulsatile abdominal mass, the prevalence of STS was investigated. An expanded triad included similar and related signs commonly registered for patients with rAAA, and was referred to as the modified abdominal aortic aneurysm rupture signs (MARS). The MARS-signs encompassed (1) the registered pain-associated symptoms or signs, (2) all hypovolemic associated signs, and (3) pulsatile abdominal mass and/or ultrasound finding, and the prevalence was similarly investigated. Finally, the STS and MARS were compared to evaluate the usefulness and performance of the MARS-score., Results: A total of 216 patients were identified. The majority were men (77%) with a median age of 78 years. The dominating symptom was abdominal pain (84%), followed by dizziness (50%). Few patients presented with three STS (13%), two STS were found in 37% and one STS in almost half of the patients (41%). By contrast, when applying MARS 35% presented with the complete expanded triad, 47% with two and 17% with one. Comparison of accuracy favored MARS (13 vs. 35% with 3 signs, P < 0.001 for STS vs. MARS) (2 or 3 signs, 48 vs. 82% STS vs. MARS, P < 0.001)., Conclusions: The expanded MARS-signs could aid in easier and faster identification of rAAA patients, thus facilitating the first step with accurate diagnosis into the lifesaving rAAA care chain. Supportive diagnostic mnemonics and tools are especially important when targeting fatal diagnoses such as rAAA. Further studies are needed to investigate the implementation of the MARS-signs in various clinical settings., (© 2024. The Author(s).)

Large-vessel vasculitis (LVVs) is a rare inflammatory disease that predominantly affects young females' aorta and its main branches, coronary arteries, and pulmonary arteries. Clinical manifestations result from vascular stenosis, occlusion, and dilation, sometimes complicated by aneurysm rupture or dissection. Early diagnosis and treatment of LVVs are paramount to reducing the risk of ischemic complications such as visual loss and strokes, vascular stenosis and occlusion, and aortic aneurysm formation. The diagnosis of LVVs is often challenging because the presenting clinical features are nonspecific in many cases and are often shared by different types of autoimmune and inflammatory diseases including other systemic vasculitides. Prompt identification of vasculitides is important because they are associated with an increased risk of mortality. Left undiagnosed or mismanaged, these conditions may result in serious adverse outcomes that might otherwise have been avoided or minimized. We report a rare case of the LVVs with multisystemic vascular aneurysms and catastrophic complications of ruptured abdominal aortic aneurysm. Our case highlights that an early diagnosis of the diverse manifestations of vasculitis and a high index of clinical suspicion is essential to avoid delays in disease recognition that may result in permanent or life-threatening morbidity., Competing Interests: Declaration of competing interest All authors declare that there is no conflict of interest., (Copyright © 2023 Hellenic Society of Cardiology. Published by Elsevier Inc. All rights reserved.)

Objective: The prevalence of abdominal aortic aneurysms (AAA) increases with age. Elective intervention for AAA is critical to prevent rupture associated with very high mortality among older males., Methods: The aim of this study was to address the impact of post-contrast acute kidney-PC-AKI injury among patients treated with endovascular repair of ruptured AAA-EVAR on outcomes such as new onset chronic kidney disease-CKD and mortality among patients within a two-year trial., Results: The same study group (of n  = 192 patients) underwent reassessment, two years after EVAR treatment. The overall mortality rate was 16.67%, and it was higher in the AKI group - 38.89%. CKD patients had a mortality rate of 23.88% ( n  = 16). Among patients with an aneurysm diameter >67 mm mortality rate reached 20% ( n  = 6), while in the previously reported diabetes mellitus group 37.93% ( n  = 11). New onset of CKD was diagnosed in 23% of cases. Preexisting CKD patients with PC- AKI contributed to a 33.33% mortality rate ( n  = 8)., Conclusion: This study concludes that PC-AKI impacts outcomes and survival in endovascularly treated AAAs. Type 2 diabetes and preexisting chronic kidney disease are associated with higher mortality within a 2-year follow-up, however gender factor was not significant. A larger aneurysm diameter is related with a higher prevalence of PC-AKI. These factors should be taken into account during screening, qualifying patients for the treatment and treating patients with AAA. It may help to identify high-risk individuals and tailor preventive measurements and treatment options accordingly, improving treatment results and reducing mortality.

Purpose: The aim of this study was to investigate the clinical and multi-slice spiral computed tomography angiography (MSCTA) characteristics for the diagnosis of infected AAA., Methods: This retrospective comparative study included patients who were diagnosed with AAA at our hospital between January 2014 and May 2023., Results: A total of 40 patients were included, comprising 20 with infected AAA and 20 with non-infected AAA. Patients with infected AAA were more likely to be younger (62.9 ± 10.1 vs. 70.0 ± 4.4 years, P = 0.007) and to present with fever [7 (35%) vs. 1 (5%), P = 0.026], pain [15 (75%) vs. 2 (10%), P < 0.001], higher C-reactive protein levels (60.4 ± 57.0 vs. 4.1 ± 2.9 mg/l, P = 0.005), and higher erythrocyte sedimentation rates (47.7 ± 23.4 vs. 15.2 ± 8.3 mm/h, P < 0.001) compared to those with non-infected AAA. Moreover, those with infected AAA exhibited significantly more eccentric saccular morphology [17 (85%) vs. 1 (5%), P = 0.002], a smaller longitudinal-transverse ratio (1.12 ± 0.33 vs. 2.33 ± 0.54, P = 0.001), thicker peri-aneurysmal soft tissue (2.29 ± 1.48 vs. 0.73 ± 0.55 cm, P < 0.001), more lobulated margins [18 (90%) vs. 1 (5%), P = 0.001], lower aortic calcification scores (49 vs. 56, P < 0.001), more pneumatosis [6 (30%) vs. 0 (0%), P = 0.014], more ruptures [15 (75%) vs. 5 (20%), P = 0.002], more blurred peri-abdominal aortic fat spaces [16 (80%) vs. 2 (10%), P = 0.001], more adjacent bone destruction [5 (25%) vs. 0 (0%), P = 0.025], more involvement of the psoas major muscle [8 (40%) vs. 1 (5%), P = 0.005], more lymphadenectasis [8 (40%) vs. 1 (5%), P = 0.020], and less tortuous aortas [2 (10%) vs. 9 (45%), P = 0.034] compared with those with non-infected AAA., Conclusion: The clinical manifestations and MSCTA characteristics may differ between infected and non-infected AAA., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The purpose of this paper is to examine and assess the outcomes following open repair in 39 patients who experienced aorto-caval fistula (ACF) resulting from the spontaneous rupture of an abdominal aortic aneurysm (AAA)., Methods: We reviewed the clinical records of all patients surgically treated with open repair for ACF at the Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Center in Belgrade, Serbia, from January 2012 to February 2023. All of the patients in this series were consecutive and had aorto-caval fistula from AAA. No patients were excluded from the procedure due to the life-threatening nature of the state. A follow-up assessment was performed during the follow-up examination or by telephone interview with the patient or a family member., Results: All patients were male, with mean age 67.4±8.3 years (range: 52-83 years). The 30-day mortality rate in our cohort was 35.9%, with three (7.7%) intraoperative deaths, and 11 deaths in the postoperative period (28.2%). A total of 25 patients out of 39 (64.1%) in the original cohort have survived the surgery and the postoperative period and were followed-up for a total of 67.1 person-years. The mean follow-up was 3.7±2.2 years (range 0.25-8.4 years). Two patients (8.0%) died during the follow-up, 16 patients (64.0%) survived, and seven (28.0%) were lost to follow-up. The long-term mortality rate in the cohort that survived the postoperative period was 3.0/100 person-years., Conclusions: ACF caused by spontaneous AAA rupture into the inferior caval vein or iliac veins is a relatively rare, life-threatening condition which requires prompt treatment. An exact preoperative diagnosis is essential for perioperative strategy. As the comparison of our results with the results from contemporary literature indicates, wherever possible endovascular repair should be considered since it results might be superior to open repair.

The presence of an intraperitoneal source of infection, e.g., a liver abscess, can be an obstacle to performing an abdominal aortic surgery with a midline laparotomy because graft infection is one of the most critical complications of aortic surgery. We report the successful Y-grafting of a pararenal abdominal aortic aneurysm through a retroperitoneal approach in a 67-year-old male undergoing liver abscess drainage. The retroperitoneal approach to the abdominal aorta may be useful for abdominal aortic surgery in patients with a localized intraperitoneal infection., Competing Interests: No potential conflict of interest relevant to this article was reported.

Objective: Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs)., Methods: Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation., Results: We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients., Conclusions: Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type., Competing Interests: Disclosures None. The opinions expressed here are those of the authors, employed by the Veterans Affairs, and do not necessarily reflect the position of the Department of Veterans Affairs or the United States government., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Abdominal aortic aneurysmal (AAA) repair in patients with concomitant cancer is controversial due to increased comorbidity and reduced life expectancy in this specific patient group. This literature review aims to investigate the evidence supporting one treatment modality over another (endovascular aortic repair (EVAR) or open repair (OR)), as well as treatment strategy (staged AAA-, cancer first or simultaneous procedures) in patients with AAA and concomitant cancer., Methods: Literature review, including studies published from 2000 to 2021 on surgical treatment in patients with AAA and concomitant cancer and related outcomes (30-day morbidity/complications as well as 30-day and 3-year mortality)., Results: 24 studies comprising 560 patients undergoing surgical treatment of AAA and concomitant cancer were included. Of these, 220 cases were treated with EVAR and 340 with OR. Simultaneous procedures were performed in 190 cases, 370 received staged procedures. The 30-day mortality for EVAR versus OR was 1% and 8%, corresponding to a relative risk (RR) of 0.11 (95% CI: 0.03-0.46, p = 0.002). No difference in mortality was observed between staged versus simultaneous procedure nor between AAA-first versus cancer-first strategy, RR 0.59 (95% CI: 0.29-1.1, p = 0.13) and 0.88 (95% CI 0.34-2.31, p = 0.80), respectively. Overall, 3-year mortality was 21% for EVAR and 39% for OR from 2000-2021, while the mortality up to 3 years after EVAR within recent years (2015-2021) was 16%., Conclusion: This review supports EVAR treatment as first choice if suitable. No consensus was established on treating either the aneurysm or the cancer first or simultaneously . Long-term mortality after EVAR was comparable to non-cancer patients within recent years., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article

Obesity, characterized by its complexity and heterogeneity, has emerged as a significant public health concern. Its association with increased incidence and mortality of cardiovascular diseases stems not only from its complications and comorbidities but also from the endocrine effects of adipose tissue. Abdominal aortic aneurysm (AAA), a chronic inflammatory condition, has been closely linked to obesity. Intriguingly, mild obesity appears to confer a protective effect against AAA mortality, whereas severe obesity and being underweight do not, giving rise to the concept of the "obesity paradox". This review aims to provide an overview of obesity and its paradoxical relationship with AAA, elucidate its underlying mechanisms, and discuss the importance of preoperative weight loss in severely obese patients with AAA., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Lu, Lin, Zhou, Chen, Liu, Zhong and Wang.)

Competing Interests: Disclosures None.

BACKGROUND Elderly patients with severe or multiple comorbidities can be at high risk for complications of general anesthesia. This report is of a 74-year-old man with severe comorbidities, including ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD), and successful abdominal aortic aneurysm repair with thoracic segmental spinal anesthesia. CASE REPORT The patient, aged 74, had previously been diagnosed with severe COPD and IHD. He was classified as American Society of Anesthesiology (ASA) grade IV, diagnosed with an abdominal aortic aneurysm (AAA) measuring 6 cm in diameter, and had to undergo surgical repair of the aneurysm with the insertion of a synthetic graft. Due to a shortage of beds in the ICU and the desire to avoid the complications associated with general anesthesia, the decision was made to proceed with thoracic spinal regional anesthesia, which is not a customary choice for this type of surgery. Spinal anesthesia was administered at the Th10-11 level, utilizing 8.5 mg of Bupivacaine, 50 mcg of Fentanyl, and 4 mg of Dexason. An epidural catheter was placed at the same level. The surgical procedure lasted 145 min and was successfully completed under regional anesthesia. CONCLUSIONS This report has highlighted that developments in spinal thoracic anesthesia mean that this can be a successful alternative to general anesthesia in high-risk patients, even for major emergency surgery.

Background : A mycotic aortic aneurysm is a rare type of aortic aneurysm that can have disastrous outcomes. Most mycotic aneurysms originate from infectious sources, such as trauma, vegetation in the heart, and adjacent infectious sources. If a mycotic aneurysm is diagnosed, it should be treated simultaneously with the primary source of the infection. Case Summary : Treatment was performed for a mycotic aneurysm of the brachial artery that occurred suddenly during treatment for a fever for which the primary source of infection had not been confirmed. The workup revealed that a mycotic aneurysm of the brachial artery was the cause of the fever, followed by aneurysms in the abdomen and lower extremities and even vegetation in the heart that was not initially present. The patient declined to undergo treatment for personal reasons. After 5 months, it was revealed that the abdominal aortic aneurysm, which was initially considered normal aorta, was ruptured; however, the aneurysm was successfully treated. Conclusions : A peripheral mycotic aneurysm may be associated with multiple aneurysms. Appropriate diagnosis and complete treatments are necessary to prevent fatal consequences.

Currently, the primary factor indicating the necessity of an operation for an abdominal aortic aneurysm (AAA) is the diameter at its widest part. However, in practice, a large number of aneurysm ruptures occur before reaching a critical size. This means that the mechanics of aneurysm growth and remodeling have not been fully elucidated. This study presents a novel method for assessing the elastic properties of an aneurysm using an ultrasound technique based on tracking the oscillations of the vascular wall as well as the inner border of the thrombus. Twenty nine patients with AAA and eighteen healthy volunteers were considered. The study presents the stratification of a group of patients according to the elastic properties of the aneurysm, depending on the relative volume of intraluminal thrombus masses. Additionally, the neural network analysis of CT angiography images of these patients shows direct (r = 0.664271) correlation with thrombus volume according to ultrasound data, the reliability of the Spearman correlation is p = 0.000215. The use of finite element numerical analysis made it possible to reveal the mechanism of the negative impact on the AAA integrity of an asymmetrically located intraluminal thrombus. The aneurysm itself is considered as a complex structure consisting of a wall, intraluminal thrombus masses, and areas of calcification. When the thrombus occupies > 70% of the lumen of the aneurysm, the deformations of the outer and inner surfaces of the thrombus have different rates, leading to tensile stresses in the thrombus. This poses a risk of its detachment and subsequent thromboembolism or the rupture of the aneurysm wall. This study is the first to provide a mechanistic explanation for the effects of an asymmetrical intraluminal thrombus in an abdominal aortic aneurysm. The obtained results will help develop more accurate risk criteria for AAA rupture using non-invasive conventional diagnostic methods., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Tikhvinsky et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Postoperative acute kidney injury (AKI) is one of the most frequent complications in abdominal aortic aneurysm (AAA) patients after open and endovascular aortic aneurysm repair. AKI decreases the efficiency of kidney function, allowing accumulation of waste products in the body, and an imbalance of water, acid and electrolytes in the body. As a result, the functioning of various organs throughout the body is affected. These effects may raise the cost of treatment, length of stay, and mortality rate., Objective: This study aims to examine the predictive factors of AKI - preoperative of estimated glomerular filtration rate (eGFR), preoperative of hemoglobin level, types of abdominal aortic aneurysms repair, and intraoperative of cardiac arrhythmias - after open and endovascular aortic repair among AAA patients within 72 h., Methods: This is a retrospective study of 196 patients with AAA after elective open and endovascular aortic aneurysm repair within the first 72 h who met the inclusion criteria recruited from a tertiary care hospital in Bangkok, Thailand. Postoperative AKI after elective open and endovascular aortic repair among AAA patients is defined by the 2012 Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines., Results: A total of 196 AAA patients, 75.5% were male with an average age of 75.12 years (SD = 8.45). Endovascular aortic aneurysm repair was used more frequently than open aortic aneurysm repair (64.8% vs 35.2%) and 37.2% of the AAA patients had intraoperative cardiac arrhythmias. The occurrence of AKI among the AAA patients after abdominal aortic aneurysm repair within 72 h was 54.1%. The AKI rate of EVAR patients was 69.8% while the AKI rate for OAR patients was 30.2%. The preoperative estimated glomerular filtration rate (eGFR) and hemoglobin level were found to jointly predict AKI and explain 32.2% of the variance (Nagelkerke R 2 = 0.322, p < .05). However, the type of abdominal aortic aneurysms repair and intraoperative cardiac arrhythmias did not correlate with the incidence of AKI in AAA repair patients. The predictive factors for AKI among AAA patients after aortic aneurysm repair were preoperative eGFR < 60 mL/min/1.73 m 2 (OR = 4.436, 95% CI: 2.202-8.928, p < .001) and preoperative hemoglobin level between 8.1-10.0 g/dL (OR = 4.496, 95% CI: 1.831-11.040, p = .001)., Conclusion: Preoperative eGFR < 60 mL/min/1.73 m 2 and preoperative hemoglobin level between 8.1-10.0 g/dL were the predictive factors for AKI among AAA patients after both open and endovascular AAA repair. Therefore, healthcare providers should be aware of and monitor signs of AKI after surgery in AAA patients, especially those undergoing EVAR with lower eGFR and hemoglobin levels., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To assess whether outcomes of rupture repair differ by aortic repair history and determine the ideal approach for rupture repair in patients with previous aortic repair., Methods: This retrospective review included all patients who underwent repair of a ruptured infrarenal abdominal aortic aneurysm from 2003 - 2021 recorded in the Vascular Quality Initiative (VQI) registry. Pre-operative characteristics and post-operative outcomes and long term survival were compared between patients with and without prior aortic repair. To assess the impact of open and endovascular approaches to rupture, a subgroup analysis was then performed among patients who ruptured after a prior infrarenal aortic repair. Univariable and adjusted analyses were performed to account for differences in patient characteristics and operative details., Results: A total of 6 197 patients underwent rupture repair during the study period, including 337 (5.4%) with prior aortic repairs. Univariable analysis demonstrated an increased 30 day mortality rate in patients with prior repairs vs. without (42 vs. 36%; p = .034), and prior repair was associated with increased post-operative renal failure (35 vs. 21%; p < .001), respiratory complications (32 vs. 24%; p < .001), and wound complications (9 vs. 4%; p < .001). Following adjustment, all outcomes were similar with the exception of bowel ischaemia, which was decreased among patients with prior repair (OR 0.7, 95% CI 0.6 - 0.9). Subgroup analysis demonstrated that patients with a prior aortic repair history who underwent open rupture repair had increased odds for 30 day death (OR 1.3, 95% CI 1.2 - 1.7) and adverse secondary outcomes compared with those managed endovascularly., Conclusion: Prior infrarenal aortic repair was not independently associated with increased morbidity or mortality following rupture repair. Patients with a prior aortic repair history demonstrated statistically significantly higher mortality and morbidity when treated with an open repair compared with an endovascular approach. An endovascular first approach to rupture should be strongly encouraged whenever feasible in patients with prior aortic repair., (Copyright © 2024 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Abdominal aortic aneurysm (AAA) rupture prediction based on sex and diameter could be improved. The goal was to assess whether aortic calcification distribution could better predict AAA rupture through machine learning and LASSO regression., Methodology: In this retrospective study, 80 patients treated for a ruptured AAA between January 2001 and August 2018 were matched with 80 non-ruptured patients based on maximal AAA diameter, age, and sex. Calcification volume and dispersion, morphologic, and clinical variables were compared between both groups using a univariable analysis with p = 0.05 and multivariable analysis through machine learning and LASSO regression. We used AUC for machine learning and odds ratios for regression to measure performance., Results: Mean age of patients was 74.0 ± 8.4 years and 89% were men. AAA diameters were equivalent in both groups (80.9 ± 17.5 vs 79.0 ± 17.3 mm, p = 0.505). Ruptured aneurysms contained a smaller number of calcification aggregates (18.0 ± 17.9 vs 25.6 ± 18.9, p = 0.010) and were less likely to have a proximal neck (45.0% vs 76.3%, p < 0.001). In the machine learning analysis, 5 variables were associated to AAA rupture: proximal neck, antiplatelet use, calcification number, Euclidian distance between calcifications, and standard deviation of the Euclidian distance. A follow-up LASSO regression was concomitant with the findings of the machine learning analysis regarding calcification dispersion but discordant on calcification number., Conclusion: There might be more to AAA calcifications that what is known in the present literature. We need larger prospective studies to investigate if indeed, calcification dispersion affects rupture risk., Clinical Relevance Statement: Ruptured aneurysms are possibly more likely to have their calcification volume concentrated in a smaller geographical area., Key Points: • Abdominal aortic aneurysm (AAA) rupture prediction based on sex and diameter could be improved. • For a given calcification volume, AAAs with well-distributed calcification clusters could be less likely to rupture. • A machine learning model including AAA calcifications better predicts rupture compared to a model based solely on maximal diameter and sex alone, although it might be prone to overfitting., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Background: The aim of this cohort study was to report the proportion of patients who develop periprocedural acute kidney injury (AKI) after endovascular repair (ER) and open surgery (OS) in patients with juxta/pararenal abdominal aortic aneurysm and to assess potential risk factors for AKI. The study also aimed to report the short- and long-term outcomes of patients with and without AKI., Methods: This was a multicenter cohort study of five European academic high-volume centers (>50 OS or 50 ER infrarenal AAA repairs, plus >15 complex AAA repairs per year). All consecutively treated patients were extracted from a prospective vascular surgical registry and the data were scrutinized retrospectively. The primary end point for this study was the development of AKI. AKI was diagnosed when there is a two-fold increase of serum creatinine or decrease of glomerular filtration rate of >50% within 1 week of AAA repair. Secondary end points included long-term mortality and end-stage renal disease (ESRD)., Results: AKI occurred in 16.6% of patients in the ER group vs 30.3% in the OS group (P < .001). The 30-day mortality rate was higher among patients with AKI in both ER (15.4% vs 3.1%; P = .006) and OS (13.2% vs 5.3%; P = .001) groups. Age, chronic kidney disease, presence of significant thrombus burden in the pararenal region, >1000 mL blood loss in ER group were associated with development of AKI. Age, diabetes mellitus, chronic kidney disease, presence of significant thrombus burden in the pararenal region, and a proximal clamping time of >30 minutes in the OS group were associated with the development of AKI, whereas renal perfusion during clamping was the protective factor against AKI development. After a median follow-up of 91 months, AKI was associated with higher mortality rates in both the ER group (58.9% vs 29.7%; P < .001) and the OS group (61.5% vs 27.3%; P < .001). After the same follow-up period, AKI was associated with a higher incidence of ESRD in both the ER group (12.8% vs 3.6%; P = .009) and the OS group (9.9% vs 2.9%; P < .001)., Conclusions: The current study identified important pre and postoperative factors associated with AKI after juxta/pararenal abdominal aortic aneurysm repair. Patients with postoperative AKI had significantly higher short- and long term mortality and higher incidence of ESRD than patients without AKI., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Fenestrated endovascular aneurysm repair (FEVAR) has become a mainstay in treating complex aortic aneurysms, though baseline patient factors predicting long-term outcomes remain poorly understood. Proteinuria is an early marker for chronic kidney disease and associated with adverse cardiovascular outcomes, but its utility in patients with aortic aneurysms is unknown. We aimed to determine whether preoperative proteinuria impacts long-term survival after FEVAR., Methods: A single-institution, retrospective review of all elective FEVAR was performed. Preoperative proteinuria was assessed by urinalysis: negative (0-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-299 mg/dL), and 3+ (≥300 mg/dL). The cohort was stratified by patients with proteinuria (≥30 mg/dL) vs those without (<30 mg/dL). Baseline, perioperative, and long-term outcomes were compared. The primary outcome, all-cause mortality, was evaluated by Kaplan-Meier analysis and independent predictors with Cox proportional hazards modeling., Results: Among 181 patients who underwent standard FEVAR from 2012 to 2022 (mean follow-up 33 months), any proteinuria was noted in 30 patients (16.6%). Patients with proteinuria were more likely to be Black (10.0% vs 1.3%) with a lower estimated glomerular filtration rate (eGFR) (52.7 ± 24.7 vs 67.7 ± 20.5 mL/min/1.73 m 2 ), higher Society for Vascular Surgery comorbidity score (10.9 ± 4.3 vs 8.2 ± 4.7) and calcium channel blocker therapy (50.0% vs 29.1%), and larger maximal aneurysm diameter (67.2 ± 16.9 vs 59.8 ± 9.8 mm) (all P < .05). Thirty-day mortality was higher in the proteinuria group (10.0% vs 1.3%; P = .03). Overall survival at 1 and 5 years was significantly lower for those with proteinuria (71.5% vs 92.3% and 29.5% vs 68.1%; log-rank P < .001). On multivariable analysis, preoperative proteinuria was independently associated with over threefold higher hazard of mortality (hazard ratio [HR]: 3.21, 95% confidence interval [CI]: 1.66-6.20; P < .001), whereas preoperative eGFR was not predictive (HR: 0.99, 95% CI: 0.98-1.01; P = .28). Additional significant predictors included chronic obstructive pulmonary disease (HR: 2.04), older age (HR: 1.05), and larger maximal aneurysm diameter (HR: 1.03; all P < .05)., Conclusions: In our 10-year experience with FEVAR, preoperative proteinuria was observed in 17% of patients and was significantly associated with worse survival. In this cohort, proteinuria was independently associated with all-cause mortality, whereas eGFR was not, suggesting that urinalysis may provide an additional simple metric for risk-stratifying patients before FEVAR., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. All rights reserved.)

Background: Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered., Methods: A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included., Results: The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes., Discussion: Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient., Conclusion: The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms., (© 2024. The Author(s).)

Background: Information on the predictive determinants of abdominal aortic aneurysm rupture from CT angiography are scarce. The aim of this study was to investigate biomechanical parameters in abdominal aortic aneurysms and their association with risk of subsequent rupture., Methods: In this retrospective study, the digital radiological archive was searched for 363 patients with ruptured abdominal aortic aneurysms. All patients who underwent at least one CT angiography examination before aneurysm rupture were included. CT angiography results were analysed to determine maximum aneurysm diameter, aneurysm volume, and biomechanical parameters (peak wall stress and peak wall rupture index). In the primary survival analysis, patients with abdominal aortic aneurysms less than 70 mm were considered. Sensitivity analyses including control patients and abdominal aortic aneurysms of all sizes were performed., Results: A total of 67 patients who underwent 109 CT angiography examinations before aneurysm rupture were identified. The majority were men (47, 70%) and the median age at the time of CTA examination was 77 (71-83) years. The median maximum aneurysm diameter was 56 (interquartile range 46-65) mm and the median time to rupture was 2.13 (interquartile range 0.64-4.72) years. In univariable analysis, maximum aneurysm diameter, aneurysm volume, peak wall stress, and peak wall rupture index were all associated with risk of rupture. Women had an increased HR for rupture when adjusted for maximum aneurysm diameter or aneurysm volume (HR 2.16, 95% c.i. 1.23 to 3.78 (P = 0.007) and HR 1.92, 95% c.i. 1.06 to 3.50 (P = 0.033) respectively). In multivariable analysis, the peak wall rupture index was associated with risk of rupture. The HR for peak wall rupture index was 1.05 (95% c.i. 1.03 to 1.08) per % (P < 0.001) when adjusted for maximum aneurysm diameter and 1.05 (95% c.i. 1.02 to 1.08) per % (P < 0.001) when adjusted for aneurysm volume., Conclusion: Biomechanical factors appear to be important in the prediction of abdominal aortic aneurysm rupture. Women are at increased risk of rupture when adjustments are made for maximum aneurysm diameter alone., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Background: Type II endoleak is the most common complication of endovascular aneurysm repair. Retrograde perfusion from the aneurysmal sac side branch to the aneurysmal sac, including the inferior mesenteric artery and lumbar arteries, is associated with adverse events after endovascular aneurysm repair, such as aneurysm sac enlargement, reintervention, rupture, and abdominal aortic aneurysm-related death. Preemptive embolization of the aneurysmal sac side branch before endovascular aneurysm repair is an effective and safe procedure for preventing type II endoleak and reducing the size of the aneurysmal sac. Since 2019, we have been conducting preemptive embolization of the inferior mesenteric artery and lumbar arteries. Thus, we intended to work on a two-stage endovascular aneurysm repair in which embolization and endovascular aneurysm repair are performed on separate days, owing to concerns about prolonged operative time and increased contrast media use and radiation exposure from performing endovascular aneurysm repair simultaneously. This study aimed to evaluate the effects of a two-stage endovascular aneurysm repair., Methods: This retrospective study included 114 cases of endovascular aneurysm repair (95 men and 19 women) for AAA performed at our hospital between January 2019 and December 2022. Inferior mesenteric artery and lumbar artery embolization were performed simultaneously with endovascular aneurysm repair (simultaneous group) in 49 cases, and two-stage embolization was performed (two-stage group) in 30 cases. The primary endpoints included the occurrence of T2EL during follow-up and the embolization rate of the IMA or LAs., Results: Type II endoleak did not occur in the two-stage group (follow-up period: 35 ± 6.2 months), whereas it was observed in 8.2% of patients more than 6 months after EVAR in the simultaneous group (follow-up period: 28 ± 5.5 months). While the total operative time was 340 ± 111.2 min in the simultaneous group, the durations for embolization and endovascular aneurysm repair in the two-stage group were 169 ± 35.5 min and 135.0 ± 26.4 min (total time 304 ± 31.2 min, P = 0.21), respectively, indicating a reduction in the total time required for the 2 techniques. The total amounts of contrast media used in the simultaneous and two-stage groups were 200.0 ± 179.2 mL and 182.0 ± 51.2 mL (P = 0.42), respectively, and the corresponding total radiation doses were 2502.4 ± 690.5 mGy and 2114.6 ± 351.2 mGy (P = 0.28), respectively, showing a decrease in both in the two-stage group. The lumbar artery embolization rates were 74.3% and 87.9% (P < 0.01) in the simultaneous and two-stage groups, respectively, indicating a significant difference., Conclusions: Two-stage endovascular aneurysm repair with preemptive embolization of the inferior mesenteric artery and lumbar arteries may be an effective strategy for reducing type II endoleak occurrence, overall operative time, contrast use, and overall radiation exposure., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Endovascular treatment of thoracoabdominal aortic aneurysms has become common, with satisfactory results. Nevertheless, long-term durability remains an issue mainly because of target visceral vessel (TVV) instability. Currently, no covered stent has been approved as a bridging stent graft (BSG), demanding continuous research on this topic., Methods: This was a multicenter observational retrospective cohort study comparing the midterm results of the Bard Covera Plus and Gore VBX as BSGs during branched endovascular aneurysm repair. The primary outcome was the comparison of the target vessel instability between the two groups. Primary patency, freedom from branch-related type I and III endoleaks and reintervention, and technical and clinical success were considered secondary outcomes. Logistic regression analysis was used to assess the association between selected baseline factors and TVV instability. TVV instability during follow-up was then evaluated using the Kaplan-Meier cumulative function., Results: Three hundred forty-five TVVs in 106 patients were considered suitable for the analysis. Two hundred twenty vessels were stented with the Covera stent graft (64%) and 125 with VBX (36%). Two hundred ninety-nine TVVs received a single BSG, 45 two BSGs, and only 1 three BSGs. Bare metal stent relining was required in 36% of TVVs, mostly in the Covera group (89 [41%] vs 36 [29%]) (P = .030). The primary technical success rate was 96% (331/345), and the assisted primary technical success rate was 99% (342/345). The TVV instability rate within 30 days was 2% (one Covera and five VBX; P = .015). Three BSG occlusions (one Covera and two VBX) and three type Ic endoleaks (three VBX) were detected. The median follow-up was 13.9 months (range, 5.8-25.5 months). Sixteen TVV instabilities were detected during the follow-up. Twelve BSG occlusions (six Covera and six VBX), three type Ic endoleaks (one Covera and two VBX), and one type IIIc endoleak (VBX). The overall target vessel instability rate was 5% (16/342). TVV instability was associated with the use of Gore VBX in the univariable logistic regression (odds ratio, 3.0; 95% confidence interval, 1.1-8.0; P = .027). Aneurysm rupture and aneurysm diameter were also associated with TVV instability in the univariable analysis (P = .002 and P = .008, respectively). The only factor predisposing to TVV instability in the multivariable logistic regression analysis was the use of Gore VBX as a BSG (odds ratio, 2.9; 95% confidence interval, 1.0-8.0; P = .043). Kaplan-Meier analysis showed a significantly higher risk of TVV instability in the VBX group (P < .001)., Conclusions: Overall midterm outcomes in this cohort were satisfactory. Patency rates were similar between the two stents. Nevertheless, VBX seems to be associated with worse TVV instability. These results may be correlated with a higher incidence of type Ic endoleaks, which require an extensive learning curve for correct stent selection and deployment., Competing Interests: Disclosures None., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality., Methods: The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality., Results: Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25)., Conclusions: LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Endoleaks are the most common complication after endovascular aneurysm repair (EVAR). Computed tomography angiography (CTA) is presently the golden standard for lifelong surveillance after EVAR. Several studies and meta-analyses have shown contrast-enhanced ultrasound (CEUS) to be a good alternative. The main goal of our study was to further validate the inclusion of CEUS in follow-up examination protocols for the systematic surveillance after EVAR., Methods: A retrospective analysis of patients who had received CEUS as part of their routine surveillance after EVAR at our center was conducted. Detection rate and classification of endoleak types were compared between available postinterventional CTA/magnetic resonance angiography and follow-up CEUS examinations. Last preinterventional CTAs before EVAR served as baselines with focus on potential cofactors such as age, body mass index, maximum aortic aneurysm diameters, endoleak orientation, and distance-to-surface influencing detection rates and classification., Results: In total, 101 patients were included in the analysis. Forty-four endoleaks (43.5% of cases) were detected by either initial CEUS or CTA, mostly type II (37.6% of the included patients). Initial CEUS showed an endoleak sensitivity of 91.2%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 84.6%. No covariate with an influence on the correct classification could be identified either for CEUS or CT., Conclusions: CEUS should be considered a valid complementary method to CTA in the lifelong surveillance after EVAR. As type II endoleaks seem to be a common early-term, sometimes spontaneously resolving complication that can potentially be missed by CTA, we suggest combined follow-up protocols including CEUS in the early on postinterventional assessment., (Copyright © 2024. Published by Elsevier Inc.)

Objective: With an aging patient population, an increasing number of octogenarians are undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) in the United States. Multiple studies have shown that, for the general population, use of local anesthetic (LA) for EVAR is associated with improved short-term and long-term outcomes as compared with performing these operations under general anesthesia (GA). Therefore, this study aimed to study the association of LA for elective EVARs with perioperative outcomes, among octogenarians., Methods: The Vascular Quality Initiative database (2003-2021) was used to conduct this study. Octogenarians (Aged ≥80 years) were selected and sorted into two study groups: LA (Group I) and GA (Group II). Our primary outcomes were length of stay and mortality. Secondary outcomes included operative time, estimated blood loss, return to operating room, cardiopulmonary complications, and discharge location., Results: Of the 16,398 selected patients, 1197 patients (7.3%) were included in Group I, and 15,201 patients (92.7%) were in Group II. Procedural time was significantly shorter for the LA group (114.6 vs 134.6; P < .001), as was estimated blood loss (152 vs 222 cc; P < .001). Length of stay was significantly shorter (1.8 vs 2.6 days; P < .001), and patients were more likely to be discharged home (LA 88.8% vs GA 86.9%; P = .036) in the LA group. Group I also experienced fewer pulmonary complications; only 0.17% experienced pneumonia and 0.42% required ventilator support compared with 0.64% and 1.02% in Group II, respectively. This finding corresponded to fewer days in the intensive care unit for Group I (0.41 vs 0.69 days; P < .001). No significant difference was seen in 30-day mortality cardiac, renal, or access site-related complications. Return to operating room was also equivocal between the two groups. Multivariate regression analysis confirmed GA was associated with a significantly longer length of stay and significantly higher rates of non-home discharge (adjusted odds ratio [AOR], 1.59; P < .001 and AOR, 1.40; P = .025, respectively). When stratified by the New York Heart Association classification system, classes I, II, III, and IV (1.55; P < .001; 1.26; P = .029; 2.03; P < .001; 4.07; P < .001, respectively) were associated with significantly longer hospital stays., Conclusions: The use of LA for EVARs in octogenarians is associated with shorter lengths of stay, fewer respiratory complications, and home discharge. These patients also experienced shorter procedure times and less blood loss. There was no statistically significant difference in 30-day mortality, return to operating room, or access-related complications. LA for octogenarians undergoing EVAR should be considered more frequently to shorten hospital stays and decrease complication rates., Competing Interests: Disclosures None., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Chronic kidney disease (CKD) and end-stage renal disease are traditionally associated with worse outcomes after endovascular aortic repair (EVAR) and open aneurysm repair (OAR) of abdominal aortic aneurysms (AAAs). However, there needs to be more data on complex AAA repair involving the aorta's visceral segment. This study stratifies complex AAA repair outcomes by CKD severity and dialysis dependence., Methods: All patients undergoing elective OAR and fenestrated/branched EVAR (F-BEVAR) for complex AAA with preoperative renal function data captured by the Vascular Quality Initiative between January 2003 and September 2020 were analyzed. Patients were stratified by CKD class as follows: normal/mild (CKD 1 and 2), moderate (CKD class 3a), moderate to severe (CKD 3b), severe (CKD class 4 and 5), and dialysis. Only patients with clamp sites above one of the renal arteries were included for complex OAR. For F-BEVAR, patients with proximal landing zones below zone 5 (above celiac artery) were included, and distal landing zones between zones 1 and 5 were excluded. Primary outcomes were perioperative and 1-year mortality. Predictors of mortality were identified by Cox multivariate regression models., Results: We identified 7849 elective complex AAA repairs: 4230 (54%) complex OARs and 3619 (46%) F-BEVARs. Most patients were White (89%) and male (74%), with an average age of 72 ± 8 years. The patients who underwent F-BEVAR were older and had more comorbidities. Elective F-BEVAR for complex AAA started in 2012 and increased from 1.4% in 2012 to 58% in 2020 (P < .001). The OAR cohort had more perioperative complications, but less 1-year mortality. The normal/mild CKD cohort had the highest 1-year survival compared with other groups after both complex OAR and F-BEVAR. On Cox regression analysis, when compared with CKD 1-2, worsening CKD stage (CKD 3b: hazard ratio [HR], 2.5; 95% confidence interval [CI], 1.82-3.40; P < .001; CKD 4-5: HR, 1.9; 95% CI, 1.16-3.26; P = .011; and dialysis: HR, 4.4; 95% CI, 2.53-7.72; P < .001) were independently associated with 1-year survival after F-BEVAR. After complex OAR, worsening CKD stage but not dialysis was associated with 1-year mortality compared with CKD 1-2 (CKD 3b: HR, 1.6; 95% CI, 1.13-2.35; P = .009; CKD 4-5: HR, 3.4; 95% CI, 2.03-5.79; P < .001)., Conclusions: CKD severity is an essential predictor of perioperative and 1-year mortality after complex AAA repair, irrespective of the treatment modality, which may reflect the natural history of CKD. Consideration should be given to raising the threshold for elective AAA repair in patients with moderate to severe CKD and end-stage renal disease, given the high 1-year mortality rate., Competing Interests: Disclosures C.H.T. has been a consultant for and received research support from Cook Medical Inc., W. L. Gore & Associates, Inc., and Phillips Healthcare. M.L.K. has been a consultant for W. L. Gore & Associates, Inc. This article's other editors and reviewers have no relevant financial relationships to disclose per the JVS policy., (Copyright © 2023 Society for Vascular Surgery. All rights reserved.)

Objective: Post implantation syndrome (PIS) is an early systemic inflammatory response following endovascular aortic repair (EVAR). The response is variable in patients and the clinical significance of PIS upon outcomes is unknown. This study aims to evaluate the incidence, risk factors, and prognostic implication of PIS., Methods: Systematic literature review and analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines of PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Eligible English-language studies regarding PIS after infrarenal EVAR were included, after removing duplicates., Results: After screening, 31 studies were included. A total of 2847 patients were reviewed, with mean age of 70.7 years, of which 2012 (90.4%) were male, with a pooled mean follow-up of 26.1 months. PIS was reported in 25.3% of cases, with mean aneurysm diameter of 56.4 cm. Polytetrafluoroethylene (PTFE) grafts were utilized in 794 patients (27.9%) with polyester in 1839 (64.6%). White blood cell count, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 levels were all significantly elevated postoperatively. Thirty-day outcomes included type I endoleak rate of 0.8%, type II endoleak rate of 1.7%, reintervention rate of 0.35%, and mortality rate of 0.25%. Subgroup pooled analysis of patients with PIS (n = 309) vs No-PIS (n = 691) revealed that polyester (n = 642), rather than PTFE (n = 234) grafts, were associated with a higher rate of PIS (94.8% vs 3.7%; P = .0001), White blood cell count was higher in the PIS group both preoperatively (7.61 vs 6.76 × 10 9 /L; P = .04) and postoperatively (15.0 vs 9.8 × 10 9 /L; P = .0007) and IL-6 levels were higher in the PIS group postoperatively (98.6 vs 25.2 pg/mL; P = .02). Aneurysm diameter and amount of chronic or new thrombus within the aneurysm sac was not identified as a risk factor for PIS. Pooled outcomes of patients with PIS vs No-PIS demonstrated a significantly higher rate of 30-day mortality (0.6% vs 0%; P = .03) and major adverse cardiac events (5.8% vs 0.43%; P < .0001) without any differences seen in reintervention or 30-day type I or type II endoleaks., Conclusions: This systematic review suggests that polyester grafts are strongly associated with PIS compared with PTFE. Interestingly, this report is suggestive of an association between 30-day mortality and major adverse cardiac events and PIS. Given these clinical sequelae, consideration for use of PTFE over polyester grafts to reduce the incidence of PIS may be a simple step to improve overall outcome. Further, exploration of the relationship between inflammatory mediators associated with PIS and mortality and cardiac complications may engender deeper understanding of risks, leading to eventual mitigation of harm for patients experiencing PIS., Competing Interests: Disclosures None., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Unlike western countries, which have reported distinct decreases in incidence of ruptured abdominal aortic aneurysm (rAAA) over the last few decades, epidemiologic studies in Korea have not shown significant changes in incidence or mortality of rAAA. The purpose of this study was to analyze the changes in rAAA treatment outcomes and various associated risk factors over the past 2 decades., Methods: A 20-year retrospective multicenter review for rAAA cases from the period of January 2000 to December 2020 was undertaken. Preoperative, intraoperative and postoperative clinical data were extracted for patients diagnosed with rAAA. For analysis, outcomes from the early era, defined as patients treated between January 1, 2000, and December 31, 2010, were compared with outcomes from the late era, defined as patients treated between January 1, 2011, and December 31, 2020., Results: The total in-hospital mortality was 34.1% in the early era compared to 44.8% in the late era. Patients in the late era were older than those in the early era (75.2 ± 10.3 years vs. 70.3 ± 8.9 years; P = 0.009). Treatment with rAAA endovascular aneurysm repair increased from 2.3% in early to 13.8% in late era (P = 0.031). In the early era, more patients were operated by experienced surgeons than the late era (78.1% vs. 45.9%; P = 0.002). The emergency room to operating room time did not show improvement over the 20 years., Conclusions: The results indicate that mortality rate of rAAA in Korea has not changed over the last 2 decades. The study suggests the need for national preventive strategies, improved systemic coordination, and potential centralization of vascular services to enhance survival rates for rAAA., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To explore the prognostic role of frailty in patients with abdominal aortic aneurysm (AAA) by conducting this systematic review and meta-analysis METHODS: We conducted an extensive literature search on PubMed, Web of Sciences, and Embase databases to identify studies that reported the association of frailty with postoperative complications, reintervention, or all-cause mortality in patients with AAA after surgery. Short-term mortality was defined by a combination of in-hospital and 30-day death., Results: Seven cohort studies reporting on 9 articles with 323,788 AAA patients were included. The reported prevalence of frailty in AAA patients ranged between 2.3% and 34.6%. Pooling the results revealed that frailty was significantly associated with a higher risk of short-term all-cause mortality (adjusted risk ratios [RR] 3.20; 95% confidence intervals [CI] 1.95-5.26), long-term all-cause mortality (adjusted RR 2.86; 95% CI 2.57-3.17), and postoperative complications (adjusted RR 2.19; 95% CI 1.50-3.20) compared to non-frail individuals. However, there was no clear association between frailty and reintervention (HR 1.44; 95% CI 0.97-2.16)., Conclusions: Frailty independently predicts the short and long-term survival as well as postoperative complications in patients with AAA undergoing surgery. Assessing frail status may potentially enhance surgical decision-making for these patients., (Copyright © 2024 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Background: The historical size threshold for abdominal aortic aneurysm (AAA) repair is widely accepted to be 5.5 cm for men and 5.0 cm for women. However, contemporary AAA rupture risks may be lower than historical benchmarks, which has implications for when AAAs should be repaired. Our objective was to use contemporary AAA rupture rates to inform optimal size thresholds for AAA repair., Methods: We used a Markov chain analysis to estimate life expectancy for patients with AAA. The primary outcome was AAA-related mortality. We estimated survival using Social Security Administration life tables and published contemporary AAA rupture estimates. For those undergoing repair, we modified survival estimates using data from the Vascular Quality Initiative and Medicare on complications, late rupture, and open conversion. We used this model to estimate the AAA repair size threshold that minimizes AAA-related mortality for 60-year-old average-health men and women. We performed a sensitivity analysis of poor-health patients and 70- and 80-year-old base cases., Results: The annual risk of all-cause mortality under surveillance for a 60-year-old woman presenting with a 5.0 cm AAA using repair thresholds of 5.5 cm, 6.0 cm, 6.5 cm, and 7.0 cm was 1.7%, 2.3%, 2.7%, and 2.8%, respectively. The corresponding risk for a man was 2.3%, 2.9%, 3.3%, and 3.4% for the same repair thresholds, respectively. For a 60-year-old average-health woman, an AAA repair size of 6.1 cm was the optimal threshold to minimize AAA-related mortality. Life expectancy varied by <2 months for repair at sizes from 5.7 cm to 7.1 cm. For a 60-year-old average-health man, an AAA repair size of 6.9 cm was the optimal threshold to minimize AAA-related mortality. Life expectancy varied by <2 months for repair at sizes from 6.0 cm to 7.4 cm. Women in poor health, at various age strata, had optimal AAA repair size thresholds that were >6.5 cm, whereas men in poor health, at all ages, had optimal repair size thresholds that were >8.0 cm., Conclusions: The optimal threshold for AAA repair is more nuanced than a discrete size. Specifically, there appears to be a range of AAA sizes for which repair is reasonable to minmized AAA-related mortality. Notably, they all are greater than current guideline recommendations. These findings would suggest that contemporary AAA size thresholds for repair should be reconsidered., (Copyright © 2024 Society for Vascular Surgery. All rights reserved.)

Rationale: A hostile iliac access route is an important consideration when enforcing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA). Herein, we report a case of AAA with unilateral external iliac artery occlusion, for which bifurcated EVAR was successfully performed using a single femoral and brachial artery access., Patient Concerns: A 76-year-old man who had undergone surgery for lung cancer 4.5 years prior was diagnosed AAA by computed tomography (CT)., Diagnosis: Two and a half years before presentation, CT revealed an infrarenal 48 mm AAA, which had enlarged to 57 mm by 2 months preoperatively. CT identified occlusion from the right external iliac artery to the right common femoral artery, with no observed ischemic symptoms in his right leg. The right external iliac artery, occluded and atrophied, had a 1 to 2 mm diameter., Intervention: Surgery was commenced with the selection of a Zenith endovascular graft (Cook Medical) with an extended body length. Two Gore Viabahn VBX balloon expandable endoprosthesis (VBX; W.L. Gore & Associate) were delivered from the right axilla as the contralateral leg., Outcomes: CT scan on the 2nd day after surgery revealed no endoleaks., Lessons: While the long-term results remain uncertain, this method may serve as an option for EVAR in patients with unilateral external iliac artery occlusion., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Pseudoaneurysms are false aneurysms that mostly occur at the site of arterial injury. Pseudoaneurysm is the most frequent complication after catheter-associated interventions and occurs because of an insufficient closure of the puncture site. However, there are several reported cases of patients with pseudoaneurysm without a prior history of vascular intervention. We described a case of ruptured giant abdominal aortic pseudoaneurysm in a patient with no prior history of vascular intervention, with an initial complaint of abdominal pain. The patient successfully received EVAR therapy using a kissing graft.

Background: Association between depression and aneurysm has been implicated but the specific role of depression in aneurysm remains unclear. We aimed to comprehensively characterize the relation of major depressive disorder (MDD) with aneurysm by subtype., Methods: Harnessing summary statistics from genome-wide association studies (N case /N control  = 7603/317,899 for aortic aneurysm; 7321/317,899 for thoracic aortic aneurysm; 3201/317,899 for abdominal aortic aneurysm; 1788/317,899 for cerebral aneurysm; and 246,363/561,190 for major depressive disorder), we estimated the genetic correlation between MDD and each of four aneurysm subtypes via LD Score Regression and tested the causality via various estimators under the bi-directional Mendelian randomization (MR) framework., Results: Positive genetic correlation of statistical significance, ranging between 0.15 (with thoracic aortic aneurysm, P = 0.005) and 0.25 (with abdominal aortic aneurysm, P = 0.001), was consistently observed for MDD with each aneurysm subtype. In the MR analysis of MDD as an exposure, genetic liability to MDD causally increased the risk of cerebral (odds ratio: 1.71; 95 % confidence interval: 1.26-2.34) but not aortic aneurysm. Replication analysis of an independent dataset (N case /N control  = 6242/59,418) corroborated this signal. In contrast, causal effect was not evident for any neurysm subtype on susceptibility to MDD., Limitations: Aneurysm could have been underdiagnosed if asymptomatic, leading to an underestimated causal impact on MDD. Non-linearity of the causal effect was not tested due to the lack of individual-level data., Conclusions: Depression and aneurysm may share common pathomechanisms. Screening depressed population and improving the clinical management for depression may benefit the primary prevention of cerebral aneurysm., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier B.V.)

Objectives: The management of type 1B endoleaks following endovascular aortic aneurysm repair (EVAR) can be challenging. The Heli-FX Endoanchor system effectively treats proximal type 1A endoleaks but has not been used for type 1B common iliac artery endoleaks. This study demonstrates that it is both safe and effective in being used in the common iliac artery (CIA) limb of an EVAR., Methods: A retrospective review of patients identified through coding and medical records was performed to extract information on demographics, aneurysmal features, operative features, and postoperative outcomes. This was then collated and analysed thoroughly and compared to existing research., Results: Four patients with six type 1B CIA endoleaks were treated with Heli-FX Endoanchors in the CIA limbs of EVAR grafts. There was 100% technical success rate with complete exclusion of the endoleaks at 6 months. With mean follow up of 714 days, there were no Endoanchor-specific complications. One patient required explantation of the aortic endograft due to contralateral limb fracture, where it was found that an Endoanchor had penetrated the common iliac vein, requiring primary closure., Conclusions: Heli-FX Endoanchors were effective within this cohort of patients, though key risks were identified. Adjacent anatomy to the CIA must be considered, which also have nearly half the arterial thickness compared to the aorta. Pre-operative planning is essential given the theoretical risk of placing Endoanchors., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Open abdominal aortic aneurysm repair (OAR) is a major vascular procedure that incurs a large physiologic demand, increasing the risk for complications such as postoperative delirium (POD). We sought to characterize POD incidence, identify delirium risk factors, and evaluate the effect of delirium on postoperative outcomes. We hypothesized that POD following OAR would be associated with increased postoperative complications and resource utilization., Methods: This was a retrospective study of all OAR cases from 2012 to 2020 at a single tertiary care center. POD was identified via a validated chart review method based on key words and Confusion Assessment Method assessments. The primary outcome was POD, and secondary outcomes included length of stay, non-home discharge, 90-day mortality, and 1-year survival. Bivariate analysis as appropriate to the data was used to assess the association of delirium with postoperative outcomes. Multivariable binary logistic regression was used to identify risk factors for POD and Cox regression for variables associated with worse 1-year survival., Results: Overall, 198 OAR cases were included, and POD developed in 34% (n = 67). Factors associated with POD included older age (74 vs 69 years; P < .01), frailty (50% vs 28%; P < .01), preoperative dementia (100% vs 32%; P < .01), symptomatic presentation (47% vs 27%; P < .01), preoperative coronary artery disease (44% vs 28%; P = .02), end-stage renal disease (89% vs 32%; P < .01) and Charlson Comorbidity Index score >4 (42% vs 26%; P = .01). POD was associated with 90-day mortality (19% vs 5%; P < .01), non-home discharge (61% vs 30%; P < .01), longer median hospital length of stay (14 vs 8 days; P < .01), longer median intensive care unit length of stay (6 vs 3 days; P < .01), postoperative myocardial infarction (7% vs 2%; P = .045), and postoperative pneumonia (19% vs 8%; P = .01). On multivariable analysis, risk factors for POD included older age, history of end-stage renal disease, lack of epidural, frailty, and symptomatic presentation. A Cox proportional hazards model revealed that POD was associated with worse survival at 1 year (hazard ratio, 3.8; 95% confidence interval, 1.6-9.0; P = .003)., Conclusions: POD is associated with worse postoperative outcomes and increased resource utilization. Future studies should examine the role of improved screening, implementation of delirium prevention bundles, and multidisciplinary care for the most vulnerable patients undergoing OAR., Competing Interests: Disclosures None., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Limited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock., Methods: We performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality., Results: Detailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality., Conclusions: Hypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible., Competing Interests: Disclosures None., (Copyright © 2023 Society for Vascular Surgery. All rights reserved.)

Clinical Impact: Studies have shown that the biomechanical indicators based on multi-scale models are more effective in accurately assessing the rupture risk of AAA. To meet the need for clinical monitoring and rapid decision making, the typical morphological parameters associated with AAA rupture and their relationships with the mechanical environment have been summarized, which provide a reference for clinical preoperative risk assessment of AAA., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Despite the evidence of good performance, carbon dioxide (CO 2 ) routine employment as a contrast agent for endovascular procedures is far from being adopted with its use currently limited to patients with renal impairment and known allergy to iodinated contrast medium (ICM). The purpose of our study is to evaluate the safety and effectiveness of CO 2 guided endovascular abdominal aortic aneurysm repair (EVAR) in a standard population and to assess the rationale for a future widespread use., Methods: We retrospectively collected data of every patient who underwent CO 2 guided standard EVAR from September 2020 to May 2021 and compared them with the data of every patient who underwent EVAR using ICM from December 2019 to August 2020 in our unit. The selection of the contrast medium was not based on any preoperative factor as the contrast medium was routinely used in every patient in both periods. The primary end point of the study was the technical success rate. Secondary end points were the early and late complication rates, radiation exposure and renal function impairment., Results: 49 patients underwent ICM guided EVAR and 52 patients underwent CO 2 guided EVAR in our unit in the time frames specified above. The technical success rate was 100% in both groups with no accidental coverage of any target vessel. Intraoperative endoleaks were observed in 14% of ICM patients and 25% of CO 2 patients. The radiation exposure was higher in the CO 2 group if compared to the ICM group (311.48 vs. 159.86 median mGy/cm 2 - P < 0.001). The incidence of postoperative acute kidney injury was low and similar in the 2 groups. No significant worsening over time of the renal function has been reported in both groups., Conclusions: EVAR can be safely performed under CO 2 guidance without the integration of any quantity of ICM but with an increase in radiation exposure. The nephroprotective role of CO 2 guided EVAR in a standard population is unclear and the same role in renal impaired patients should be validated with further studies on selected populations., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Although obese patients seem to be susceptible to chronic diseases, obesity paradox has been observed in the field of vascular surgery, in which many previous studies have reported that overweight patients have good postoperative outcomes and underweight patients have poor postoperative outcomes. The purpose of our study is to evaluate the impact of body mass index (BMI) and serum albumin levels, which are evaluated as indicators of nutritional status, on outcomes of open abdominal aortic aneurysm (AAA) repair., Methods: We reviewed the vascular surgery database of a single tertiary referral center for all patients who underwent open AAA repair due to degenerative etiology from 1996 to 2021. To analyze the effect of BMI, patients were classified into 4 groups according to the Asian-Pacific classification of BMI: underweight (UW) (<18.5 kg/m 2 ), normal weight (NW) (18.5-22.9 kg/m 2 ), overweight (OW) (23-24.9 kg/m 2 ), and obese (OB) (≥25 kg/m 2 ). The χ 2 , Fisher's exact, and Kruskal-Wallis tests were used to compare demographics, comorbidities, radiologic findings, surgical details, and 1-year mortality rates between the 4 groups. We also compared the preoperative serum albumin levels of each group to assess nutritional status indirectly. Cox's proportional hazards model was performed to determine factors associated with mortality. A Kaplan-Meier survival analysis was performed, and the differences were analyzed by a log-rank test. We did not perform an analysis for 30-day mortality because cases of 30-day mortality in UW patients were rare due to the unbalanced distribution of the number of patients in the 4 groups., Results: Among a total of 678 patients, 22 were classified as UW (3.2%), 200 as NW (29.5%), 183 as OW (27.1%), and 273 as OB (40.1%). The median age was 70 (64-75) years and 577 of 678 (85.1%) patients were male gender. Higher serum albumin level was associated with decreased 1-year mortality (hazard ratio [HR], 0.3; 95% confidence interval [CI], 0.15-0.63; P = 0.001). UW patients had a higher 1-year mortality rate than NW patients (HR, 3.67; 95% CI, 1.02-13.18; P = 0.046). OB patients had a lower overall mortality rate than NW patients (HR, 0.73; 95% CI, 0.53-1; P = 0.05)., Conclusions: Low BMI (<18.5 kg/m 2 ) and low serum albumin level were associated with poor 1-year survival after elective open AAA repair. These patients also need more careful preoperative intervention, like weight gain or nutritional support, for better outcomes. The obesity paradox existed in our study; high BMI (≥25 kg/m 2 ) was associated with better overall survival after elective open AAA repair., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Morphologically, the risk of aortic aneurysm rupture is mainly evaluated based on its type (e.g., fusiform or saccular) and diameter. Based on the finite element analysis, peak wall stress has been identified as a more sensitive and specific predictor of rupture in recent years. Moreover, in finite analysis, the neck of aneurysm is the highest peak wall stress and is associated with the rupture point., Case Presentation: A saccular aortic aneurysm (84 mm) was incidentally detected during preoperative examination for chronic empyema in a 74-year-old male patient with a history of polycythemia. Aortic arch graft replacement using an open stent was performed., Conclusions: Morphologically, this case was associated with a very high risk of rupture; nevertheless, it did not rupture. In this case, a mural thrombus (likely formed due to polycythemia) covered the neck of aneurysm that is experiencing the highest peak wall stress and is associated with the rupture point. The mural thrombus decreased peak wall stress and could reduce the risk of rupture even for huge saccular aneurysms. Furthermore, the mural thrombus was fully occupied in aneurysms, such as during coil embolization. Thus, polycythemia could decrease the risk of rupture of huge saccular aneurysms., (© 2024. The Author(s).)

Aim: Ruptured abdominal aortic aneurysm (rAAA) is associated with a high mortality rate which, is especially significant in rural and provincial regions. In Aotearoa New Zealand, Māori experience higher rates of AAA and worse overall medium-term survival following AAA repair. This study aimed to understand the prevalence of incidental AAA on routine abdominal computed tomography (CT) scans over 12 months., Method: A retrospective review of all abdominal CT scans performed on patients ≥50 years at Gisborne Hospital between 1 December 2018-1 December 2019 was performed., Results: A total of 811 scans were reviewed, with 42 incidental AAA detected (5.2%). The majority of incidental AAA were in males aged ≥65 (65.8%), with a higher prevalence for Māori compared to New Zealand European (NZE) (16.2% vs 8.1%, p=0.052). This pattern was also seen in females, aged ≥65 (10.9% in Māori vs 3.8% in NZE, p=0.047)., Conclusion: The detection of AAA on routine abdominal CT scans appears to be a useful adjunct in lieu of targeted AAA screening in our region. A high prevalence of incidental AAA (5.2%) over 12 months, with a significantly higher prevalence noted in Māori males and females ≥65 years (16.2% and 10.9%), was observed., Competing Interests: Nil., (© PMA.)

Background: Prophylactic embolization of the inferior mesenteric artery (IMA) during endovascular aneurysm repair (EVAR) is recommended to prevent type 2 endoleak (T2EL). However, the impact of patent lumbar arteries (LAs) on T2ELs and aneurysm diameter has not been elucidated., Methods: Fifty-seven consecutive patients who underwent EVAR at our institution between January 2013 and September 2022 and whose IMA had been occluded preoperatively or newly occluded postoperatively were included in the study. Predictive factors for aneurysm sac enlargement, sac shrinkage, and T2EL were investigated., Results: T2ELs occurred in 22.8% of the patients. The 4-year cumulative incidence rates of sac enlargement and shrinkage were 6.7% and 64.6%, respectively. The number of postoperative patent LAs was identified as a risk factor for T2ELs (95% confidence interval [CI]: 1.54-12.7, P = 0.0065). The number of postoperative patent LAs was found to be a significant predictor of sac enlargement (adjusted hazard ratio [AHR] 3.15, 95% CI: 1.43-6.96, P = 0.0045) and shrinkage (AHR 0.63, 95% CI: 0.43-0.91, P = 0.014)., Conclusions: The current study demonstrated that the number of postoperative patent LAs had a significant impact on the development of T2ELs and the change in aneurysm diameter in patients in whom the IMA was occluded after EVAR., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Evaluate how specific morphologic aspects of abdominal aortic aneurysms (AAAs), including asymmetries, curvatures, tortuosities, and angulations, among others can influence the intrinsic biomechanical properties of the AAA's wall. This study analyzed the correlation of geometric measurements (1-dimensional, 2-dimensional, and 3-dimensional) of preoperative tomographic images of AAA with uniaxial biomechanical tests of the arterial wall fragments of these AAA obtained in open surgical repair of aneurysms., Methods: It was a multicenter, experimental, and observational study, and initially 54 individuals were selected who underwent open surgical of AAA, with valid biomechanical tests of the anterior wall of the AAA. Seven individuals were excluded because they had poor preoperative quality computed tomography scans and/or artifacts that impeded image segmentation and extraction of AAA geometric indices. The aortic fragments were subjected to uniaxial biomechanical destructive tests to obtain the following data: maximum load, failure stress, failure tension, failure strain energy, strain, and fragment thickness. In the same patients, preoperative computed tomography scans were performed with the extraction of 26 geometric indices, subdivided into 9 1-dimensional indices, 6 2-dimensional indices, and 11 3-dimensional indices. Data were subjected to statistical analysis using SPSS version 28., Results: Comparing ruptured and unruptured AAA, no statistical difference was observed between the biomechanical and geometric parameters. The fragment thickness of the ruptured AAA was lower than that of the unruptured AAA (P < 0.05). By comparing tomographic geometric indices and biomechanical parameters of the aortic fragments using Pearson's coefficient, positive and linear correlations (P < 0.05) were observed between the geometric variable maximum diameter (Dmax) of the AAA with maximum load (r = 0.408), failure tension (r = 0.372), and failure stress (r = 0.360). Positive and linear correlations were also observed between the variable diameter/height ratio (DHr) and the maximum load (r = 0.360), failure tension (r = 0.354), and failure stress (r = 0.289). The geometric variable DHr was dependent and correlated with Dmax. Simple regression analysis showed that R 2 varied between 8.3% and 16.7%, and all models were significant (P < 0.05)., Conclusions: Dmax and DHr were linearly and positively correlated with the resistance parameters (maximum load, failure tension, and failure stress) of the AAA fragments. The DHr variable is dependent and correlated with Dmax. There was no correlation between the other geometric indices and the biomechanical parameters of the AAA wall. The asymmetries did not globally influence the biomechanics of AAA wall; however, they may influence regionally. Larger AAAs were stronger than smaller ones. Therefore, such findings may point toward Dmax is still the main geometric parameter, which influences the anterior wall, and possibly globally in the AAA., (Copyright © 2023 Elsevier Inc. All rights reserved.)