Late Open Abdominal Aneurysm Reconstruction and Graft Salvage in a Patient With Persistent Endoleak Type II Following Endovascular Aneurysm Repair.

This study highlights a case of late open conversion repair (OCR) for persistent Type II endoleak after endovascular aneurysm repair (EVAR), presenting a 78-year-old male with a history of EVAR for an infrarenal abdominal aortic aneurysm. Despite conservative management of the initial endoleak, the aneurysm sac's progressive growth necessitated open reconstruction to salvage the graft. Successful postoperative outcomes emphasize the critical need for meticulous intervention strategies and surveillance in managing persistent Type II endoleaks. This case underlines the importance of a tailored approach, leveraging both endovascular and open surgical techniques, to optimize long-term outcomes and prevent aneurysm rupture in complex cases.

On the feasibility of ultrasound Doppler-based personalized hemodynamic modeling of the abdominal aorta.

BACKGROUND: Personalized modeling is a promising tool to improve abdominal aortic aneurysm (AAA) rupture risk assessment. Computed tomography (CT) and quantitative flow (Q-flow) magnetic resonance imaging (MRI) are widely regarded as the gold standard for acquiring patient-specific geometry and velocity profiles, respectively. However, their frequent utilization is hindered by various drawbacks. Ultrasound is used extensively in current clinical practice and offers a safe, rapid and cost-effective method to acquire patient-specific geometries and velocity profiles. This study aims to extract and validate patient-specific velocity profiles from Doppler ultrasound and to examine the impact of the velocity profiles on computed hemodynamics. METHODS: Pulsed-wave Doppler (PWD) and color Doppler (CD) data were successfully obtained for six volunteers and seven patients and employed to extract the flow pulse and velocity profile over the cross-section, respectively. The US flow pulses and velocity profiles as well as generic Womersley profiles were compared to the MRI velocities and flows. Additionally, CFD simulations were performed to examine the combined impact of the velocity profile and flow pulse. RESULTS: Large discrepancies were found between the US and MRI velocity profiles over the cross-sections, with differences for US in the same range as for the Womersley profile. Differences in flow pulses revealed that US generally performs best in terms of maximum flow, forward flow and ratios between forward and backward flow, whereas it often overestimates the backward flow. Both spatial patterns and magnitude of the computed hemodynamics were considerably affected by the prescribed velocity boundary conditions. Larger errors and smaller differences between the US and generic CFD cases were observed for patients compared to volunteers. CONCLUSION: These results show that it is feasible to acquire the patient-specific flow pulse from PWD data, provided that the PWD acquisition could be performed proximal to the aneurysm region, and resulted in a triphasic flow pattern. However, obtaining the patient-specific velocity profile over the cross-section using CD data is not reliable. For the volunteers, utilizing the US flow profile instead of the generic flow profile generally resulted in improved performance, whereas this was the case in more than half of the cases for the patients.

The Importance of Cell Saver Usage in Complex Endovascular Repair of Thoraco-Abdominal Aortic Aneurysms.

AIM: The use of the cell-saver is well established in open aneurysm repair, however, its role in endovascular repair is yet to be determined. The aim of this study was to analyze the effects of cell-saver usage in patients undergoing complex endovascular procedures. MATERIALS AND METHODS: Single-center retrospective cohort study including consecutive patients undergoing fenestrated and/or branched repair for the treatment of thoracoabdominal and complex abdominal aortic aneurysms between January 2019 and December 2022. The cell-saver was a standard part of the intraoperative setup of these procedures and its use was readily available. The primary endpoint was the percentage of patients in which autologous blood collected was transfused (CSBT), alongside the usable amount obtained. Secondary endpoints included mean blood loss, postoperative haemoglobin levels and 30-day mortality. RESULTS: A total of 170 patients (77.1% male, mean age 71.2 ± 9.2 years) were included, with a median blood loss of 700mL (IQR 400-1200mL). A total of 96 patients received some kind of blood transfusion (BT) (56.5%): 35 (20.6%) allogenic BT, 31 (18.2%) CSBT only and 30 (17.6%) a combination of both. In total, 61 patients (35.9%, or 63.5% of all patients requiring BTs) received CSBT, with a median usable blood volume of 282mL (IQR, 194.5 - 508mL). Thirty-day mortality was similar in both groups. Although the CSBT group had lower intraoperative hemoglobin values (9.25 ± 1.55 vs. 10.36 ± 1.88 mg/dL; p<0.001), both groups presented similar postoperative hemoglobin levels. CONCLUSION: Blood loss during complex endovascular repair is not insignificant. In this cohort, over 50% of included patients required some kind of BT, 32.3% of which received exclusively CSBT while 31.3% had supplementary CSBT alongside allogenic BT. This data showcases its potential role in these repairs, paving the way for its standardization in the intraoperative setup of these complex procedures.

Geographical disparities in access to surgical treatment and mortality rates from abdominal aortic aneurysms in Brazil: A retrospective longitudinal study.

INTRODUCTION: Abdominal aortic aneurysm (AAA) is a growing public health problem, and not all patients have access to surgery when needed. This study aimed to analyze spatiotemporal variations in AAA mortality and surgical procedures in Brazilian intermediate geographic regions and explore the impact of different surgical techniques on operative mortality. METHODS: A retrospective longitudinal study was conducted to evaluate AAA mortality from 2008 to 2020 using space-time cube (STC) analysis and the emerging hot spot analysis tool through the Getis-Ord Gi* method. RESULTS: There were 34,255 deaths due to AAA, 13,075 surgeries to repair AAA, and a surgical mortality of 14.92%. STC analysis revealed an increase in AAA mortality rates (trend statistic = +1.7693, p = 0.0769) and a significant reduction in AAA surgery rates (trend statistic = -3.8436, p = 0.0001). Analysis of emerging hotspots revealed high AAA mortality rates in the South, Southeast, and Central-West, with a reduction in procedures in São Paulo and Minas Gerais States (Southeast). In the Northeast, there were extensive areas of increasing mortality rates and decreasing procedure rates (cold spots). CONCLUSION: AAA mortality increased in several regions of the country while surgery rates decreased, demonstrating the need for implementing public health policies to increase the availability of surgical procedures, particularly in less developed regions with limited access to services.

Gasdermin D Inhibitor Necrosulfonamide Alleviates Angiotensin II-Induced Abdominal Aortic Aneurysms in Apolipoprotein E-Deficient Mice.

Abdominal aortic aneurysm (AAA) is a chronic aortic disease that lacks effective pharmacological therapies. This study was performed to determine the influence of treatment with the gasdermin D inhibitor necrosulfonamide on experimental AAAs. AAAs were induced in male apolipoprotein E-deficient mice by subcutaneous angiotensin II infusion (1000 ng/kg body weight/min), with daily administration of necrosulfonamide (5 mg/kg body weight) or vehicle starting 3 days prior to angiotensin II infusion for 30 days. Necrosulfonamide treatment remarkably suppressed AAA enlargement, as indicated by reduced suprarenal maximal external diameter and surface area, and lowered the incidence and reduced the severity of experimental AAAs. Histologically, necrosulfonamide treatment attenuated medial elastin breaks, smooth muscle cell depletion, and aortic wall collagen deposition. Macrophages, CD4+ T cells, CD8+ T cells, and neovessels were reduced in the aneurysmal aortas of necrosulfonamide- as compared to vehicle-treated angiotensin II-infused mice. Atherosclerosis and intimal macrophages were also substantially reduced in suprarenal aortas from angiotensin II-infused mice following necrosulfonamide treatment. Additionally, the levels of serum interleukin-1ß and interleukin-18 were significantly lower in necrosulfonamide- than in vehicle-treated mice without affecting body weight gain, lipid levels, or blood pressure. Our findings indicate that necrosulfonamide reduced experimental AAAs by preserving aortic structural integrity as well as reducing mural leukocyte accumulation, neovessel formation, and systemic levels of interleukin-1ß and interleukin-18. Thus, pharmacologically inhibiting gasdermin D activity may lead to the establishment of nonsurgical therapies for clinical AAA disease.

Outcomes Following Different Management of Mycotic Infrarenal Abdominal Aortic Aneurysms.

OBJECTIVE: The objective was to present our experience on managing mycotic infrarenal abdominal aortic aneurysm (MIAAA) through a retrospective cohort study. METHODS: Data of patients with MIAAA managed in our center from July 2016 to October 2022 were retrospectively analyzed. The diagnosis of MIAAA was made based on: (1) preoperative clinical signs of infection; (2) elevated serologic infection parameters; (3) para-aneurysmal infection features on enhanced computed tomography; and (4) positive blood or tissue cultures. All the patients received standard antibiotic therapy. Surgical management including endovascular aneurysm repair (EVAR), initial EVAR followed by open re-operation, and initial open surgical repair (OSR) were conducted according to disease seriosity, physical condition, and patient's will. Infection index and clinical outcome were evaluated during the follow-up time. RESULTS: A total of 23 patients (21 men; averaged=66.3 years, range=49-79 years) were included, with a mean follow-up time of 19.9 months (range=1-75 months). Bacteria culture from blood or tissue specimen was positive in 15 patients (Salmonella, n=8; Escherichia coli, n=3; methicillin-sensitive Staphylococcus aureus [MSSA], n=1; Klebsiella pneumoniae, n=1; Staphylococcus epidermidis, n=1; Mycobacterium tuberculosis, n=1). Seven patients received OSR as the initial surgical intervention, whereas 14 patients chose EVAR instead. The 2 conservatively managed patients (refused surgery) died within 30 days. The 7 patients who received initial OSR survived till now. Among the 14 patients who underwent initial EVAR, infection deteriorated without exception (14/14, 100%). Three of these patients refused re-operation and died within 6 months. Eleven patients received secondary surgical intervention (10 cases of aneurysm and endograft resection, thorough debridement, subclavian to bi-femoral artery bypass, or in situ aorta reconstruction; 1 case of laparoscopic debridement) and 7 survived the follow-up time. The overall mortality rate was 39.1% (9/23). The mortality rates differed greatly following different intervention methods (merely antibiotic management, 100%; initial open operation, 0%; initial EVAR without secondary operation, 100%; initial EVAR plus secondary operation, 36.4%). CONCLUSIONS: Open surgical repair is still the first choice for hemodynamically stable and low-risk patients. Merely EVAR is related with disastrous results, which should be reserved as a temporary alternative for patients with ruptured aneurysms, hemodynamic instability or high surgical risk, and followed by timely secondary OSR. CLINICAL IMPACT: The management of mycotic or primary-infected aortic aneurysm is challenging; treatment remains controversial. Our center has reviewed our experience over the past 6 years and found that open surgical repair is still the first choice for hemodynamically stable and low-risk patients. Merely endovascular aneurysm repair (EVAR) is related with disastrous results, which should be reserved as a temporary alternative for patients with ruptured aneurysms, hemodynamic instability or high surgical risk, and followed by timely secondary open surgical repair.

Long-term outcomes of chimney endovascular aneurysm repair procedure for complex abdominal aortic pathologies.

OBJECTIVE: The aim of this study was to update our earlier experience and to evaluate long-term outcomes of chimney endovascular aortic repair performed for selected cases with complex abdominal aortic aneurysm. METHODS: A single-center retrospective cohort study was conducted on 51 consecutive patients who underwent chimney endovascular aortic repair procedure, deemed unfit for open surgical repair and fenestrated endovascular aneurysm repair, from October 2009 to November 2019. Kaplan-Meier analyses were used to assess the estimated overall survival, freedom from aneurysm related mortality, freedom from reintervention, freedom from target vessel instability, and freedom from type Ia endoleaks. RESULTS: Fifty-one patients (mean age, 77.1 ± 7.5 years) with a mean preoperative maximum aneurysm diameter of 74.2 ± 20.1 mm were included. Mean follow-up duration was 48.6 months (range, 0-136 months). Estimated overall survival at 5 and 7 years was 36.3% ± 7.1% and 18.3% ± 6.0%, respectively. Freedom from aneurysm-related mortality was 88.6% ± 4.9% at 7 years. Estimated freedom from type Ia endoleaks at 7 years was 91.8% ± 3.9%. A total of 21 late reinterventions were performed in 17 patients (33%). Most of them were performed to treat type II endoleaks with sac growth (47.6%; n = 10) and type Ib endoleak (23.8%; n = 5). Estimated freedom from reintervention at 7 years was 56.3% ± 7.9%. Estimated freedom from target vessel instability at 7 years was 91.5% ± 4.1%. CONCLUSIONS: The 7-year results of chimney endovascular aortic repair procedures performed in our center confirm the long-term safety and effectiveness of this technique in a series of high-risk patients with large aneurysms. The present study has, to the best of our knowledge, the longest follow-up for patients treated with chimney endovascular aortic repair, and it provides data to the scarce literature on the long-term outcomes of this procedure, showing acceptable to good long-term results.

Aortic aneurysms in a general population cohort: prevalence and risk factors in men and women.

BACKGROUND AND AIMS: The prevalence and difference in risk factors for having thoracic and abdominal aortic aneurysms in men compared to women in the general population is not well-described. This study aimed to test the hypotheses i) that cardiovascular risk factors for thoracic and abdominal aortic aneurysms differ and ii) that the prevalence of thoracic and abdominal aortic aneurysms is sex specific. METHODS: Aortic examination using computed tomography angiography was performed in 11,294 individuals (56% women), with a mean age of 62 [range 40-95] years participating in the Copenhagen General Population Study. Thoracic aortic aneurysms were defined as ascending aortic diameter ≥45 mm and descending aortic diameter ≥35 mm, abdominal aortic aneurysms were defined as abdominal aortic diameter ≥30 mm. Demographic data were obtained from questionnaires. RESULTS: Overall prevalence of aortic aneurysms in the study population included: total population 2.1%, men 4.0% and women 0.7% (p-test men vs. women p<0.001). Aortic aneurysms were independently associated with male sex, increasing age, and body surface area. While thoracic aortic aneurysms were associated with hypertension, odds ratio=2.0[95%CI:1.5-2.8], abdominal aortic aneurysms were associated with hypercholesterolemia and smoking, odds ratios=2.4[95%CI:1.6-3.6] and 3.2[95%CI:1.9-5.4]. CONCLUSIONS: Subclinical aortic aneurysms are four times more prevalent in men than women. In both sexes, increasing age and body surface area are risk factors for aortic aneurysms of any anatomical location. Whereas arterial hypertension is a risk factor for thoracic aortic aneurysms, hypercholesterolemia and smoking are risk factors for abdominal aortic aneurysms.

Multi-Energy Low-Kiloelectron Volt versus Single-Energy Low-Kilovolt Images for Endoleak Detection at CT Angiography of the Aorta.

Purpose To compare image quality, diagnostic performance, and conspicuity between single-energy and multi-energy images for endoleak detection at CT angiography (CTA) after endovascular aortic repair (EVAR). Materials and Methods In this single-center prospective randomized controlled trial, individuals undergoing CTA after EVAR between August 2020 and May 2022 were allocated to imaging using either low-kilovolt single-energy images (SEI; 80 kV, group A) or low-kiloelectron volt virtual monoenergetic images (VMI) at 40 and 50 keV from multi-energy CT (80/Sn150 kV, group B). Scan protocols were dose matched (volume CT dose index: mean, 4.5 mGy ± 1.8 [SD] vs 4.7 mGy ± 1.3, P = .41). Contrast-to-noise ratio (CNR) was measured. Two expert radiologists established the reference standard for the presence of endoleaks. Detection and conspicuity of endoleaks and subjective image quality were assessed by two different blinded radiologists. Interreader agreement was calculated. Nonparametric statistical tests were used. Results A total of 125 participants (mean age, 76 years ± 8; 103 men) were allocated to groups A (n = 64) and B (n = 61). CNR was significantly lower for 40-keV VMI (mean, 19.1; P = .048) and 50-keV VMI (mean, 16.8; P < .001) as compared with SEI (mean, 22.2). In total, 45 endoleaks were present (A: 23 vs B: 22). Sensitivity for endoleak detection was higher for SEI (82.6%, 19 of 23; P = .88) and 50-keV VMI (81.8%, 18 of 22; P = .90) as compared with 40-keV VMI (77.3%, 17 of 22). Specificity was comparable among groups (SEI: 92.7%, 38 of 41; both VMI energies: 92.3%, 35 of 38; P = .99), with an interreader agreement of 1. Conspicuity of endoleaks was comparable between SEI (median, 2.99) and VMI (both energies: median, 2.87; P = .04). Overall subjective image quality was rated significantly higher for SEI (median, 4 [IQR, 4-4) as compared with 40 and 50 keV (both energies: median, 4 [IQR, 3-4]; P < .001). Conclusion SEI demonstrated higher image quality and comparable diagnostic accuracy as compared with 50-keV VMI for endoleak detection at CTA after EVAR. Keywords: Aneurysms, CT, CT Angiography, Vascular, Aorta, Technology Assessment, Multidetector CT, Abdominal Aortic Aneurysms, Endoleaks, Perigraft Leak Supplemental material is available for this article. © RSNA, 2024.

Modified upside-down technique with Gore tapered iliac limbs for isolated iliac artery aneurysms.

PURPOSE: To describe the off-label use of tapered iliac limbs for the treatment of isolated iliac aneurysms with proximal landing zone significantly larger than distal landing zone. TECHNIQUE: Inversion of a Gore Excluder tapered leg (W. L. Gore & Associates Inc, Flagstaff, Arizona) with a modified upside-down technique is described. The endoprosthesis, with the olive at the tip of the releasing system previously cut, is inserted in a tip-to-tip fashion into a 15 Fr introducer sheath. The graft is released inside the introducer. An 18 Fr introducer sheath is advanced up to the proximal sealing zone. Following the removal of the 18 Fr dilator, the 15 Fr introducer with the pre-released graft is inserted co-axially into the 18 Fr introducer. A pre-cut 15 Fr dilator is brought up to the endograft and used as a pusher. A pull-back maneuver of the co-axial system, countertractioning with the dilator maintained in position, allows the delivery of the endograft. CONCLUSION: This technique might offer a feasible option in case of endovascular exclusion of isolated iliac artery aneurysms with significant landing zone diameter mismatch. Extracorporeal inversion is time-saving and could be safer in terms of graft damage and infection.

Increasing abdominal aortic aneurysm curvature visibility using 3D dual probe bistatic ultrasound imaging combined with probe translation.

High frame rate ultrasound (US) imaging techniques in 3D are promising tools for capturing abdominal aortic aneurysms (AAAs) over time, however, with the limited number of channel-to-element connections current footprints are small, which limits the field of view. Moreover, the maximal steering angle of the ultrasound beams in transmit and the maximal receptance angle in receive are insufficient for capturing the curvy shape of the AAA. Therefore, an approach is needed towards large arrays. In this study, high frame rate bistatic 3D US data (17 Hz) were acquired with two synchronized matrix arrays positioned at different locations (multi-aperture imaging) using a translation stage to simulate what a larger array with limited channel-to-element connections can potentially achieve. Acquisitions were performed along an AAA shaped phantom with different probe tilting angles (0 up to ± 30°). The performance of different multi-aperture configurations was quantified using the generalized contrast-to-noise ratio of the wall and lumen (gCNR). Furthermore, a parametric model of the multi-aperture system was used to estimate in which AAA wall regions the contrast is expected to be high. This was evaluated for AAAs with increasing diameters and curvature. With an eight-aperture 0° probe angle configuration a 69 % increase in field of view was measured in the longitudinal direction compared to the field of view of a single aperture configuration. When increasing the number of apertures from two to eight, the gCNR improved for the upper wall and lower wall by 35 % and 13 % (monostatic) and by 36 % and 13 % (bistatic). Contrast improvements up to 22 % (upper wall) and 12 % (lower wall) are achieved with tilted probe configurations compared to non-tilted configurations. Moreover, with bistatic imaging with tilted probe configurations gCNR improvements up to 4 % (upper wall) and 7 % (lower wall) are achieved compared to monostatic imaging. Furthermore, imaging with a larger inter-probe distance improved the gCNR for a ± 15° probe angle configuration. The gCNR has an expected pattern over time, where the contrast is lower when there is more wall motion (systole) and higher when motion is reduced (diastole). Furthermore, a higher frame rate (45 Hz) yields a lower gCNR, because fewer compound angles are used. The results of the parametric model suggest that a flat array is suitable for imaging AAA shapes with limited curvature, but that it is not suitable for imaging larger AAA shapes with more curvature. According to the model, tilted multi-aperture configurations combined with bistatic imaging can achieve a larger region with high contrast compared to non-tilted configurations. The findings of the model are in agreement with experimental findings. To conclude, this study demonstrates the vast improvements in field of view and AAA wall visibility that a large, sparsely populated 3D array can potentially achieve when imaging AAAs compared to single or dual aperture imaging. In the future, larger arrays, less thermal noise, more steering, and more channel-to-element connections combined with carefully chosen orientations of (sub-) apertures will likely advance 3D imaging of AAAs.

Survival, Short And Long-Term Outcomes Of Open And Endovascular Surgical Repair Of Unruptured Infrarenal Abdominal Aortic Aneurysms.

INTRODUCTION: Endovascular Aortic Repair (EVAR) has become the standard management of Unruptured Infrarenal Abdominal Aortic Aneurysm (UIAAA); however, current evidence is limited and uncertain in our environment compared to Open repair. Our study aimed to determine the survival, short and long-term outcomes of EVAR vs. Open in a Peruvian cohort of UIAAA. METHODS: A single-center observational, analytical, longitudinal study using a retrospective registry of 251 patients treated (EVAR=205 vs Open=46) for UIAAA from 2000 to 2017. Variables considered were baseline, comorbidities, type of treatment, short-term (<30 days) and long-term (<5 years) outcomes, postoperative mortality according to the Vascular Quality Initiative (VQI) Risk Score, survival curves including reoperation-free rate and according to size (<65 mm vs. >65 mm) of long-term UIAAA. All variables were grouped according to the treatment performed (EVAR vs. Open) and we used the descriptive, multivariate, Cox regression, and Kaplan-Meier survival statistical analyses. RESULTS: 251 UIAAA were evaluated and the mean age was 74.5 years [±13.32], smoking, family members with UIAAA, and previous abdominal surgery were the main antecedents. Diabetes mellitus 2 was the main comorbidity; more than 50% of patients with UIAAA had diameters greater than 65 mm (p=0.021). The calculated mortality (VQI) was Open=2.21% vs. EVAR=1.65%. The outcomes in short-term were mortality (Open=2.92% vs. EVAR=0%; p=0.039), blood transfusion >4 Units (Open=72.68% vs. EVAR=17.39%; p=0.021) and overall hospital stay (Open=14 vs. EVAR=5 days; p=0.049. A reduction in mortality (HR 0.76, 95% CI, 0.62-0.96, p=0.045) and readmission for aneurysmal rupture was identified for EVAR (HR 0.81, 95% CI, 0.79-0.85, p=0.031). In long-term outcomes, mortality (Open=3.41% vs. EVAR=19.56%; p=0.047), aneurysmal rupture (Open=0% vs. EVAR 13.04%; p=0.032) and reinterventions (Open=2.43% vs. EVAR=10.86%; p=0.002). An 86% risk of mortality (HR 1.86, 95% CI, 1.32-2.38, p=0.039) and elevated risk of readmission for aneurysmal rupture was identified for EVAR (HR 2.21, 95% CI, 1.98-2.45, p=0.028). At 5 years, survival for Open=93.67% vs. EVAR=80.44% (p=0.043), reintervention-free survival for Open=89.26% vs. EVAR=47.82% (p=0.021), survival for treated IUAAA <65 mm for Open=95.77% vs. EVAR=63.63% (p=0.019) and >65 mm for Open=92.53% vs. EVAR=85.71% (p=0.059). CONCLUSION: EVAR has shown better short-term benefits and survival than Open management; however, the latter still prevails in the long term in our Peruvian UIAAA cohort. Further follow-up studies are required to demonstrate the long-term benefit of EVAR in our population.

Enhanced visualization in endoleak detection through iterative and AI-noise optimized spectral reconstructions.

To assess the image quality parameters of dual-energy computed tomography angiography (DECTA) 40-, and 60 keV virtual monoenergetic images (VMIs) combined with deep learning-based image reconstruction model (DLM) and iterative reconstructions (IR). CT scans of 28 post EVAR patients were enrolled. The 60 s delayed phase of DECTA was evaluated. Objective [noise, contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR)] and subjective (overall image quality and endoleak conspicuity - 3 blinded readers assessment) image quality analyses were performed. The following reconstructions were evaluated: VMI 40, 60 keV VMI; IR VMI 40, 60 keV; DLM VMI 40, 60 keV. The noise level of the DLM VMI images was approximately 50% lower than that of VMI reconstruction. The highest CNR and SNR values were measured in VMI DLM images. The mean CNR in endoleak in 40 keV was accounted for as 1.83 ± 1.2; 2.07 ± 2.02; 3.6 ± 3.26 in VMI, VMI IR, and VMI DLM, respectively. The DLM algorithm significantly reduced noise and increased lesion conspicuity, resulting in higher objective and subjective image quality compared to other reconstruction techniques. The application of DLM algorithms to low-energy VMIs significantly enhances the diagnostic value of DECTA in evaluating endoleaks. DLM reconstructions surpass traditional VMIs and IR in terms of image quality.

Abdominal aortic aneurysm healed with calcification in a female patient with Behçet's syndrome: A case report with a 2-decade follow-up.

Abdominal aortic aneurysms (AAA) are rare in Behçet syndrome (BS) but may result in life-threatening complications. AAA are generally treated with surgical intervention following aggressive immunosuppressive therapy. Healing with wall calcification and mural thrombus for AAA is scarcely reported in the literature. Herein, we present a female patient who developed a large saccular aneurysm in the infra-renal abdominal aorta 6 months after the diagnosis. Endovascular intervention was not found to be possible because of the dimensions of the aneurysm and the patient did not consent for open surgery. Therefore, she received only immunosuppressive treatment. By the second year of follow-up, we detected reduction in the size of AAA, along with circumferential wall calcification and mural thrombus. The patient was followed-up for 20 years without rupture and currently doing well. This case demonstrates that calcified large saccular AAA might not necessitate surgical intervention and be followed-up for many years without any complication.

Assessing Efficacy of Afatinib toward Elastic Matrix Repair in Aortic Aneurysms.

Abdominal aortic aneurysm (AAA) is a critical, multifactorial cardiovascular disorder marked by localized dilatation of the abdominal aorta. A major challenge to countering the pathophysiology of AAAs lies in the naturally irreversible breakdown of elastic fibers in the aorta wall, which is linked to the poor elastogenicity of adult and diseased vascular smooth muscle cells (SMCs) and their impaired ability to assemble mature elastic fibers in a chronic proteolytic tissue milieu. We have previously shown that these are downstream effects of neutrophil elastase-induced activation of the epidermal growth factor receptor (EGFR) activity in aneurysmal SMCs. The novelty of this study lies in investigating the benefits of an EGFR inhibitor drug, afatinib (used to treat nonsmall cell lung cancer), for proelastogenic and antiproteolytic stimulation of aneurysmal SMCs. In in vitro cell cultures, we have shown that safe doses of 0.5 and 1 nM afatinib inhibit EGFR and p-extracellular signal-regulated kinases 1/2 protein expression by 50-70% and downstream elastolytic matrix metalloprotease 2 (MMP2) versus untreated control cultures. In addition, elastin production on a per cell basis was significantly upregulated by afatinib doses within the 0.1-1 nM dose range, which was further validated through transmission electron microscopy showing significantly increased presence of tropoelastin coacervates and maturing elastic fibers upon afatinib treatment at the above doses. Therefore, our studies for the first time demonstrate the therapeutic benefits of afatinib toward use for elastic matrix repair in small AAAs.

Effectiveness Evaluation of Preventive Embolization of the Internal Iliac Artery in Preventing Type II Endoleaks.

Purpose The aim of this study was to evaluate the effectiveness of the proposed method of preventive embolization of the internal iliac arteries using a liquid tantalum-containing ethylene vinyl alcohol copolymer. Methods In this nonrandomized clinical study with a retrospective control group, 55 patients with aneurysmal lesions of the infrarenal abdominal aorta participated. In the course of this study, we developed and implemented a method of preventive embolization of the ostia of the internal iliac artery using a liquid tantalum containing ethylene-vinyl alcohol copolymer having viscosity of 34 centipoise. The method was applied in 27 cases in patients with aneurysmal lesions of the infrarenal abdominal aorta with unilateral involvement of the common iliac artery. The maximum follow-up period at the stage of publication of the results was 24 months. Results The proposed method of embolization of the internal iliac artery is accompanied by an absolute risk of developing type II endoleak 0.393 (95% confidence interval: 0.2120-0.5738, p = 0.029); therefore, when using the new technique, there is a decrease in the absolute risk of developing type II endoleak by 39.3%. Conclusion The proposed method of preventive embolization allows to perform reliable occlusion of the internal iliac artery as proximally as possible, which makes it possible to maintain distal blood flow in the internal iliac artery and minimizes the risks of ischemic events.

The incidence rate and histological characteristics of intimal hyperplasia in elastase-induced experimental abdominal aortic aneurysms in mice.

Intimal hyperplasia (IH) is a negative vascular remodeling after arterial injury. IH occasionally occurs in elastase-induced abdominal aortic aneurysm (AAA) mouse models. This study aims to clarify the incidence and histological characteristics of IH in aneurysmal mice. A retrospective study was conducted by including 42 male elastase-induced mouse AAA models. The IH incidence, aortic diameters with or without IH, and hyperplasia lesional features of mice were analyzed. Among 42 elastase-induced AAA mouse models, 10 mice developed mild IH (24%) and severe IH was found in only 2 mice (5%). The outer diameters of the AAA segments in mice with and without IH did not show significant difference. Both mild and severe IH lesions show strong smooth muscle cell positive staining, but endothelial cells were occasionally observed in severe IH lesions. There was obvious macrophage infiltration in the IH lesions of the AAA mouse models, especially in mice with severe IH. However, only a lower numbers of T cells and B cells were found in the IH lesion. Local cell-secreted matrix metalloproteinases (MMP) 2 was highly expressed in all IH lesions, but MMP9 was only overexpressed in severe lesions. In conclusion, this study is the first to demonstrate the occurrence of aneurysmal IH and its histological characteristics in an elastase-induced mouse AAA model. This will help researchers better understand this model, and optimize it for use in AAA-related research.

Asymptomatic Fusiform Aortic Aneurysms in a 37-Year-Old Male: A Case Report.

Abdominal aortic aneurysm (AAA) is mostly present in patients aged ≥65 years. Here, we present an unusual case of a 37-year-old male with a pair of asymptomatic, fusiform abdominal aortic aneurysms above and below the origin of the renal arteries. The patient was diagnosed with AAA in 2016 and had undergone yearly follow-ups since then. He had no major risk factors for AAA other than hypertension, which was managed with medication, and had only a brief history of smoking. He was also negative for all genetic and connective tissue defects. His aneurysms progressed slowly, with proximal and distal aneurysms currently measuring 3.9 cm and 4.5 cm, respectively. The patient was asymptomatic and was closely examined for further management.

Aortoenteric Fistula: A Differential Diagnosis of Anemia.

Aortoenteric fistulas (AEFs) are a rare and deadly cause of gastrointestinal bleeding that can be easily overlooked, leading to massive bleeding. Secondary AEFs are more common than primary AEFs. An example of a secondary cause of anemia is postoperative hemorrhage due to a surgically placed aortic graft or after endovascular aneurysm repair. This report aims to increase the awareness of AEF as a differential diagnosis when anemia is detected. The clinical report presents a case of anemia in a 79-year-old man due to a secondary AEF, which occurred in a patient who had undergone abdominal aortic aneurysm surgery 10 years before. Surgical repair is considered the gold standard for AEF treatment; however, in this case, the patient was managed with medical therapy and discharged after two months.

Efforts for detection of aortic aneurysms and human resources training for the optimization of their treatment.

OBJECTIVE: To review admissions, interventions and in-hospital mortality associated to Abdominal Aortic Aneurysms (AAA), and to analyze the impact of the introduction of a training program and imaging screening at our institution. METHODS: Retrospective study where hospitalizations, procedures and mortality secondary to AAA were recorded. The national databases (ND) from the Secretariat of Health were utilized from 2010 to 2020. In-hospital lethality was calculated and compared with the experience at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ). The statistical analysis was completed with the STATA version 17. RESULTS: According to the ND, 899 (91%) hospital admissions secondary to AAA occurred, while in the INCMNSZ 85 (9%). Most of them belonged to the male gender (68%); 811 (82%) patients underwent open surgical repair, and 173 (18%) to an endovascular exclusion (EVAR), the latter approach was significantly more frequently performed at our institution (p = 0.007). The 30-day hospital mortality was 22.5%; in the ND was 23.9 vs. a 16.4% in the INCMNSZ without significant difference (p = 0.1). CONCLUSIONS: AAA remain unrecognized in our country. The introduction of University programs and imaging screening might impact in the early detection, and to reduce the morbidity and mortality associated to emergency procedures.

OBJETIVO: Revisar los ingresos, procedimientos y defunciones intrahospitalarias asociadas a aneurismas aórticos abdominales (AAA) y analizar el impacto de la introducción de programas de formación de recursos humanos y tamizaje ultrasonográfico. MÉTODOS: Estudio retrospectivo, se analizaron las bases de datos nacionales obtenidas del portal datos abiertos de la Dirección General de Información en Salud (DGIS) del año 2010 al 2020. Se calculó la letalidad intrahospitalaria anual y comparamos la experiencia del Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ). El análisis estadístico se realizó en el programa STATA versión 17. RESULTADOS: De acuerdo con la base nacional (BN), se registraron 899 (91%) ingresos, mientras que en el INCMNSZ 85 (9%). La mayoría pertenecía al sexo masculino (68%), un total de 811 (82%) pacientes fueron sometidos a cirugía abierta, mientras que 173 (18%) a terapia endovascular (EVAR), siendo este abordaje más frecuente en nuestra institución (p = 0.007). La mortalidad intrahospitalaria fue del 22.5%, en la BN fue del 23.9%, mientras que en el INCMNSZ fue del 16.4%, sin que encontráramos diferencia significativa (p = 0.1). CONCLUSIONES: Los AAA continúan siendo poco reconocidos en nuestro país. La introducción de programas universitarios de especialidad y el tamizaje podría impactar en la reducción de la morbimortalidad.