International Collaborative Study Comparing Outcomes of Fenestrated Endovascular Aortic Repair in OCtogenarian vs Non-Octogenarian Patients: The FEVOC study.

OBJECTIVE: With an increasing life expectancy, more octogenarian patients are referred with complex aortic aneurysms (cAAA). The aim of this study was to evaluate short and mid-term outcomes following fenestrated aortic repair (FEVAR) in octogenarians. SUMMARY BACKGROUND DATA: Few studies looking at octogenarian-specific outcomes with diverging results. METHODS: Retrospective, multicentre cohort study including consecutive patients undergoing elective FEVAR for cAAAs or type IV thoracoabdominal aortic aneurysms between 2007-2022 in eight high-volume centres. Octogenarians vs. non-octogenarians were compared. The primary outcome was 30-day mortality. Secondary outcomes included 1, 2 and 5-year survival and reintervention rates. RESULTS: A total of 729 patients (median age of 74.8 years [IQR 69.2 - 79.14]) were included, 169 (23%) of which were octogenarians, with 316 (43.3%) patients undergoing juxta/pararenal aneurysm repair. Although octogenarians presented less complex but larger (61 mm vs. 58 mm) aneurysms, the number of fenestrations was similar across groups. No differences in in-hospital mortality (4.1 vs. 3.0%), MAE (16.6% vs 12.2%) or reintervention rates (11.2 vs. 10%) were found. Multivariable logistic regression of in-hospital mortality identified BMI (OR 0.66, 95% CI 0.51-0.95, P=0.003), chronic heart failure (OR 7.70, 95% CI 1.36-36.15, P=0.003) and GFR<45 ml/min/1.73 m2 (OR 5.25, 95% CI 1.20-22.86, P=0.027) as independent predictors. Median follow-up was 41 months. The 1, 2 and 5-year survival rates were 91.3%, 81.8% and 49.5% in octogenarians vs 90.6%, 86.5% and 68.8% in non-octogenarian patients (Log-rank: =0.001). Freedom from aortic-related death and freedom from reintervention at five-years were similar across groups (log-rank=0.94 and .76, respectively). Age>80 was not an independent predictor of 30-day or long-term mortality on multivariable and Cox regression analysis. CONCLUSIONS: Elective FEVAR in octogenarians appears to be safe, with similar outcomes as in younger patients. Future studies looking at improved patient selection methods to ensure long-term survival benefits in both octogenarians and younger patients are warranted.

A systematic review and meta-analysis of the incidence of acute aortic dissections in population-based studies.

OBJECTIVE: To perform a systematic review and meta-analysis of all population-based studies reporting on incidence of acute aortic dissections (AADs). METHODS: We searched the MEDLINE, EMBASE, CENTRAL, and Open Grey databases from inception to August 2020 for population-based studies reporting on the incidence of AAD. A systematic review was conducted following the PRISMA guidelines using a registered protocol (CRD42020204007). Data were pooled using a random effects model of proportions using Freeman-Tukey double arcsine transformation. The main outcome was the incidence of AAD. Secondary outcomes were incidence type A aortic dissections (TAAD) and type B aortic dissections (TBAD), the incidence of aortic dissection repair and medical management, and the incidence of in-hospital mortality. In addition, we estimated the proportion of aortic dissection repair and mortality (in hospital, overall and specific mortality according to subtype) among patients with AAD. RESULTS: Thirty-three studies were included. The pooled incidence of AADs was 4.8 per 100,000 individuals/year (95% confidence interval [CI], 3.6-6.1). The incidence of TAAD was 3.0 per 100,000/year (95% CI, 1.8-4.4) and the incidence of TBAD was 1.6 per 100,000/year (95% CI, 1.1-2.2). The incidence of AAD needing repair was 1.4 per 100,000/year (95% CI, 1.0-2.0) (or 1.4 [95% CI, 1.2-1.7] for TAAD and 0.4 [95% CI, 0.2-0.7] for TBAD). The incidence of medically managed AAD was 3.4 per 100,000/year (95% CI, 2.4-4.5). The incidence of in-hospital death owing to AAD was 1.3 per 100,000 individuals/year (95% CI, 0.9-1.9), 1.0 (95% CI, 0.6-1.4; I2 = 97%) for TAAD, and 0.3 for TBAD (95% CI, 0.2-0.4; I2 = 96%). CONCLUSIONS: A global estimate regarding the incidence rate of AADs was achieved. The incidence of AAD varied significantly between study designs and geographical regions. More accurate information on AAD epidemiology is crucial for public health decisions, clinical understanding, and healthcare management.

The Impact of the Proctor Assistance for a Safe Learning Curve in the Development of a Complex Aortic Endovascular Program.

INTRODUCTION: Initiating an endovascular aortic program for treatment of complex aortic aneurysms with fenestrated and branched grafts (FB-EVAR) is challenging. Using a Proctor is one option for training and development of the team. However, this approach has not been formally analyzed. The aim of this study was to analyze the learning curve and the effect of the Proctor regarding safety and effectiveness in FB-EVAR. METHODS: A single-center retrospective cohort study was performed, including all consecutive elective patients submitted to FB-EVAR (including both thoraco-abdominal-TAAA and complex abdominal aortic aneurysms-C-AAA) from 2013 to 2021. Patients were divided into 2 groups, the first operated with the Proctor present and the second without. Primary outcomes were 30-day mortality (safety) and technical and procedure success (efficacy). Secondary outcomes included treatment performance (procedure time, blood loss, contrast, and radiation use), re-interventions, aneurysm shrinking, target vessel patency, 30-day mortality, aneurysm-related mortality, and overall mortality. RESULTS: Overall, 105 patients were included in the study, 35 operated with Proctor and 70 operated without. The first 20 patients were operated always with the Proctor, and the remaining were operated with the Proctor selectively. Mean age was 71.8 (±7.3) years and 95 patients were male (90.5%). Overall, 62 (65%) patients had C-AAA or extent IV TAAAs and 43 (35%) had extensive TAAAs. There were no significant differences regarding 30-day mortality (Log Rank=0.99), technical success (p=0.4), or procedure success (p=0.8). Mean surgical time was longer in the non-Proctor group (p=0.005), as well as significant intra-operative blood loss (p=0.042). Contrast use (p=0.5) and radiation (p=0.53) were non-significantly different between groups. There were no significant differences regarding length of stay (p=0.4), major adverse events (p=0.6), target vessel patency (Log Rank=0.97), early (p=0.7) and late endoleaks (0.7), aneurysm shrinking (p=0.6), re-interventions (p=0.2), and overall mortality (Log Rank=0.87). CONCLUSION: In our experience, the use of a Proctor to start and accompany our complex endovascular aortic program for FB-EVAR was both safe and effective and may serve as a template by other countries and centers that aim to developing their programs.

Predictive Factors for Aortic Graft Infection: A Case-Control Study.

BACKGROUND: Graft infections are one of the most serious complications in vascular surgery, with high mortality rates. Few studies addressed risk factors associated with a higher susceptibility to infection. The aim of this study is to identify perioperative factors associated with aortic graft infections (AGI). METHODS: We designed a retrospective, case-control study from patients subjected to open aortic repair between 2013 and 2019. Cases of AGI were defined according to the management of aortic graft infection collaboration (MAGIC) criteria and matched to controls without proven infection. Demographics, hospital complications, and laboratory workups were assessed. Predictors of AGI were identified through univariate and multivariate analysis. RESULTS: Most graft infections occurred in a late period (n = 17; 85%), after a median interval of 13.5 months interquartile range (IQR 1.5-36). Gram-negative bacteria were most frequently isolated in infected grafts, namely Enterobacteriaceae (n = 12). Cases had significantly lower postoperative serum albumin levels (1.9 g/dL vs. 2.4 g/dL; P = 0.002). Alcohol abuse, malignancy, prolonged lengths of stay, wound infection and dehiscence, in-hospital infection, postoperative heart failure or bowel ischemia were significantly correlated to the onset of AGI. In the multivariate analysis, prolonged hospital stays odds ratio (OR 1.05; P = 0.03), malignancy (OR 5.82; P = 0.03) and alcohol abuse (OR 42.41; P = 0.002) maintained a significant association. CONCLUSIONS: The risk of AGI seems to be higher in patients with concurrent malignancy, alcohol abuse or prolonged hospital stays. Strategies to mitigate this complication in these patients are of utmost importance.

Microbial evolution of vascular graft infections in a tertiary hospital based on positive graft cultures.

BACKGROUND: Vascular graft infections are a serious complication in vascular surgery. Correct antibiotic therapy targeted to the most likely infecting species is essential to treat these patients, although the bacterial epidemiology and pathogenesis are still not completely understood. We analyzed the behavior of vascular graft infections and the microbiologic patterns of resistance. METHODS: A 10-year (2008-2018), single-center, retrospective cohort study was performed of all patients admitted with vascular graft infection identified by positive direct graft cultures. An extensive microbiologic study was performed to analyze the bacterial strains, antibiotic resistance and sensitivity, and prevalence stratified by the year. RESULTS: A total of 72 vascular graft infections with positive graft cultures occurring in 65 patients were found. Their mean age was 67 ± 9.6 years, and 85% were men. Infection-related mortality was 11%. Of the 65 patients, 14 had undergone aortobifemoral bypass, 13 axillofemoral bypass, 5 femorofemoral bypass, 27 femoropopliteal bypass, and 4 femoral endarterectomy with synthetic patch angioplasty. The median interval from the index procedure to infection was longer for intracavitary than for extracavitary grafts (P = .011). Of the 72 infections, 48 were monomicrobial and 24 were polymicrobial. Gram-negative bacteria were predominantly identified in intracavitary graft infections (54%). In contrast, gram-positive bacteria were most frequent in the extracavitary graft group (58%). Multidrug-resistant bacterial species occurred more frequently in early graft infections (P = .002). Throughout the study duration, an overall decrease in gram-positive infections and an increase in gram-negative infections was observed, especially in extensively drug-resistant strains. A similar progression was found in all nosocomial infections. CONCLUSIONS: The present study has shown that vascular graft infection microbiology changed in accordance with graft location and interval to infection from revascularization surgery and had also evolved over the study period with patterns similar to those for all nosocomial infections. This highlights the importance of studying the specific microbiology of each healthcare center and its relationship to vascular graft infections to achieve the best treatment possible.

Enteric repair in aortoduodenal fistulas: a forgotten but often lethal player.

BACKGROUND: An aortoenteric fistula is an abnormal communication between the aorta and the bowel lumen. It is usually caused by previous aortic surgery and involves the duodenum (ADF) in most cases. The treatment of this high-mortality condition is based on the correction of enteric and vascular defects. However, enteric repair indications and impact are unknown. OBJECTIVE: We sought to characterize the surgical procedures available for duodenal repair in ADF and estimate their impact in mortality. METHODS: A literature search was conducted, between the years 1951-2010. Cases (791 from 614 references) were individually registered and analyzed to demography, enteric location, type and cause of fistula, type of surgical procedure, mortality, and cause of death. Risk factors to outcome were estimated by univariate and multivariate analysis. RESULTS: The enteric procedure was described in 331 cases: duodenorrhaphy (with or without omentum interposition; with or without enterostomy) in 266 cases, duodenal resection/reconstruction in 54 cases, antibiotic or abdominal drainage alone in 4 cases, and nothing was done in 7 cases. Vascular treatment was described in 515 cases: extra-anatomic bypass in 207 cases, in situ graft in 197 cases, direct closure of the aortic defect in 52 cases, endovascular procedures in 32 cases, and others arterial reconstructions in 27 cases. Univariate analysis revealed that mortality caused by ADF is directly associated with primary ADF type, direct closure of the aortic defect, and is inversely associated with recent publications, omentum interposition, use of an in situ graft, and endovascular prosthesis. Multivariate analysis revealed that omentum interposition and the use of an in situ graft were independent factors to the outcome, and that omentum use was the strongest factor related to survival. The most common cause of death was ADF recurrence (41.8%), which was significantly high (P = 0.036) in the patients who underwent simple duodenorrhaphy. CONCLUSIONS: The literature supports the use of omentum interposition and suggests that duodenal derivation is preferable to the simple closure of fistula. Delayed or avoided enteric repair after endovascular treatment emerged as an option, but needs additional supporting research.

The fate of spinal arteries after the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair technique: a case series.

Objective: We evaluated the patency of the spinal arteries (intercostal and lumbar) after the STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique. Methods: A retrospective analysis of all patients with aortic dissection treated with the STABILISE technique between April 2018 and July 2021 was performed. Imaging analysis of the spinal cord vascular supply was accomplished using multiplanar and maximum intensity projection reconstructed images of pre- and postoperative computed tomography angiograms at 1 month, 12 months, and annually thereafter. Results: Twelve patients were treated for complicated aortic dissection. Primary technical success was 100% and mid-term clinical success, at a mean follow-up of 27 ± 12 months, was 90%. No cases of spinal cord ischemia were identified. One patient died after 1 year (non-aortic related), and one patient was lost to follow-up. A significant decrease was found in the mean number of patent spinal arteries in the stent graft area at 1 month (P < .001), 1 year (P < .001), and 2 years (P = .004). However, no significant reduction was found in the number of spinal arteries in either the bare metal stented or nonstented aorta (P > .05). Conclusions: Use of the STABILISE technique decreased intercostal artery patency in the thoracic stent graft area, but spinal artery patency was not significantly affected by the bare metal stent nor its aggressive ballooning. These findings constitute a step toward a better understanding of the safety of this technique.

Current perspectives in acute type B aortic dissections: a literature review.

In this new millennial, endovascular strategies have revolutionized the treatment of acute type B aortic dissection (aTBAD). With reduced in-hospital mortality and good long-term outcomes TEVAR has become the gold standard for the treatment of complicated dissection and is gaining increasing support for its preventive applicability in some uncomplicated dissections. With this new paradigm came a shift of the treatment goal where just covering the entry tear is not enough and instead achieving long-term positive thoracoabdominal remodeling is needed. More extensive approaches with composite device designs (covered stent graft and bare metal stent) emerged to answer this aortic conundrum. At 5-year of follow-up, "Provisional ExTension To Induce COmplete Attachment technique" (PETTICOAT) and its evolution "Stent assisted balloon induced intimal disruption and relamination in aortic dissection repair" (STABILISE) seem to be safe techniques that can allow, when anatomically feasible, excellent aortic remodeling and, in some cases, even the healing of the dissection. Nevertheless, STABILISE results, although promising, are mostly based on small series and therefore need to be validated by analyzing medium-long-term results from the international registry. Given the plethora of new data and the disparity of expert opinions on the best treatment to adopt, in this review we aim to summarize the current knowledge on the results of these different strategies for acute TBAD.

The evolution of management of type B aortic dissection in a series of 100 consecutive cases in a tertiary center.

INTRODUCTION AND OBJECTIVES: Management of aortic dissection is rapidly evolving. The present study aims to assess paradigm shifts in type B aortic dissection (TBAD) treatment modalities and their outcomes according to clinical presentation and type of treatment. We also aim to assess the impact of endovascular technology in TBAD management in order to define organizational strategies to provide an integrated cardiovascular approach. METHODS: We performed a retrospective review with descriptive analysis of the last 100 consecutive patients with TBAD admitted to the Vascular Surgery Department of Centro Hospitalar Universitário Lisboa Norte over a 16-year period. Results were stratified according to treatment modality and stage of the disease. The study was further divided into two time periods, 2003-2010 and 2011-2019, respectively before and after the introduction of a dedicated endovascular program for aortic dissections. RESULTS: A total of 100 patients (83% male; mean age 60 years) were included, of whom 59 were admitted in the acute stage (50.8% with complicated dissections). The other 41 patients were admitted for chronic dissections, most of them for surgical treatment of aneurysmal degeneration. Temporal analysis demonstrated an increase in the number of patients operated for aortic dissection, mainly due to an increase in chronic patients (33.3% in 2003-2010 vs. 64.4% in 2011-2019) and a clear shift toward endovascular treatment from 2015 onward. Overall in-hospital mortality was 14% and was significantly higher in the chronic phase (acute 5.1% vs. chronic 26.8%; OR 5.30, 95% CI 1.71-16.39; p=0.003) and in patients with aneurysmal degeneration, regardless of the temporal phase. Only one death was recorded in the endovascular group. CONCLUSION: Management of TABD carried an overall mortality of 14% during a 16-year period, but the appropriate use of endovascular technology has substantially reduced in-hospital mortality.

A real-world analysis of anti-atherosclerotic medical treatment and risk factor control in a cohort of vascular surgery patients.

INTRODUCTION: The aim of this study was to assess the pattern of anti-atherosclerosis medicines in patients admitted to a vascular surgery department, the effective control of the target values and its subsequent modification by the vascular surgery team. MATERIAL AND METHODS: A retrospective single-center cohort study of prospectively collected data was performed between May 2017 and May 2018 in a tertiary center. The STROBE guidelines were followed. All patients undergoing a primary elective surgery for carotid disease, aortic aneurysm and peripheral arterial disease were included. 'Best medical treatment' was defined as treatment with both anti-thrombotic and lipid-lowering treatment and, when appropriate, antihypertensive and anti-diabetic drugs. Both baseline and post-discharge best medical treatment were recorded. Blood work-up was performed at admission and 'adequately controlled patient' was defined if all blood test values were in agreement with the guidelines. RESULTS: A total of 279 patients (78% male; mean age 69 years-old) were included. Optimal medical therapy was registered in 58.8% upon admission but improved to 73.8% (95% CI, 2.197 - 7.781; p < 0.001) after discharge. At baseline, a total of 65.4% of patients were on lipid-lowering agents and of these, only 37% had LDL-C values within the targets. Likewise, only 34.6% of the 78 patients with diabetes had glycated hemoglobin within the normal range. Additionally, 8.5% of the remaining cohort had undiagnosed diabetes. CONCLUSION: In our current practice, only 75% of the patients receive best medical treatment. Although the admission in a Vascular Surgery department was an opportunity to optimize medical therapy, treatment remains suboptimal in one-quarter of patients. Further efforts should be carried out to alert vascular surgeons to this problem and to find future multidisciplinary solutions that can improve the cardiovascular risk profiles of these patients.

Introdução: Este estudo pretendeu avaliar o padrão de tratamento médico antiaterosclerótico em doentes internados num serviço de cirurgia vascular, o controlo efetivo dos valores-alvo e a sua posterior modificação pela equipa vascular. Material e Métodos: Foi realizado um estudo de coorte retrospetivo com dados coletados prospectivamente entre maio de 2017 e maio de 2018 num centro terciário. Foram seguidas as guidelines da STROBE e incluídos todos os doentes submetidos a cirurgias primárias eletivas para correção de doença carotídea, aneurisma de aorta e doença arterial periférica. Definiu-se como 'tratamento médico otimizado' o tratamento com fármacos anti-trombóticos e hipolipemiantes e, quando apropriado, com agentes anti-hipertensivos e antidiabéticos. Foi registado tratamento médico otimizado à entrada bem como após a alta. À admissão foi igualmente realizado um controlo analítico e os doentes foram classificados como 'adequadamente controlados' se todos os valores analíticos estivessem de acordo com as normas de orientação clínica. Resultados: Foram incluídos 279 pacientes (78% homens; idade média de 69 anos). O tratamento médico otimizado foi registado em 58,8% à data de admissão, tendo melhorado para 73,8% (IC 95%, 2,197 ­ 7,781; p < 0,001) após alta da enfermaria vascular. No início do estudo, 65,4% dos doentes estavam sob agentes hipolipemiantes e, destes, apenas 37% tinham valores de LDL-C dentro dos valores-alvo estabelecidos pelas normas de orientação clínica. Da forma semelhante, apenas 34,6% dos 78 doentes com diabetes tinham hemoglobina glicada dentro da normalidade. Da restante coorte, 8,5% tinha diabetes não diagnosticada. Conclusão: Na nossa prática atual apenas 75% dos pacientes seguem o tratamento médico otimizado. Apesar do internamento num serviço de Cirurgia Vascular ser uma oportunidade única para otimizar o tratamento médico, este permanece abaixo do ideal em cerca de um quarto dos doentes. Devem ser realizados esforços adicionais no sentido de alertar os cirurgiões vasculares para esse problema e encontrar soluções multidisciplinares futuras que permitam melhorar o perfil de risco cardiovascular destes doentes.

Surgical, anesthesical and perfusion strategies for open thoracoabdominal aneurysm repair.

.

Incidence of acute aortic dissections in patients with out of hospital cardiac arrest: A systematic review and meta-analysis of observational studies.

OBJECTIVES: Acute Aortic dissection (AAD) may present as out-of-hospital cardiac arrest (OHCA). However, the incidence of this presentation is not well known. Our aim was to perform a systematic review and meta-analysis of all observational studies reporting on the incidence of AAD in patients with OHCA. METHODS: We searched MEDLINE, CENTRAL, PsycInfo, Web of Science Core Collection and OpenGrey databases from inception to March-2021, for observational studies reporting on the incidence of AAD in patients with OHCA. Data was pooled using a random-effects model of proportions. The primary outcome was the incidence of AAD in OHCA patients. Secondary outcomes were the incidence of type A aortic dissections (TAAD) and type B aortic dissections (TBAD) in OHCA patients, overall mortality following AAD-OHCA and risk of death in AAD-OHCA patients compared to risk of death of non-AAD-OHCA patients. RESULTS: Fourteen studies were included. The pooled calculated incidence of OHCA due to AAD was 4.39% (95 %CI: 2.55; 6.8). Incidence of OHCA due to TAAD was 7.18% (95 %CI: 5.61; 8.93) and incidence of OHCA due to TBAD was 0.47% (95 %CI: 0.18; 0.85). Overall mortality following OHCA due to AAD was 100% (95 %CI: 97.62; 100). The risk of death in AAD-OHCA patients compared with non-AAD-OHCA patients was 1.10 (95 %CI: 0.94; 1.30). CONCLUSION: AAD as a cause of OHCA is more frequent than previously thought. Prognosis is dire, as it is invariably lethal. These findings should lead to a higher awareness of AAD when approaching a patient with OHCA and to future studies on this matter.

Incidence and Prevalence of Thoracic Aortic Aneurysms: A Systematic Review and Meta-analysis of Population-Based Studies.

Thoracic aortic aneurysms (TAA) may grow asymptomatically until they rupture, with a mortality over 90%. The true incidence and prevalence of this condition is uncertain and epidemiologic data is scarce, understudied and dispersed. Therefore, we aimed to conduct a systematic review and meta-analysis of the incidence and prevalence of TAAs in population-based studies. We searched MEDLINE, EMBASE and CENTRAL from inception to October 2020 for all population-based studies reporting on incidence and/or prevalence of TAAs. Data were pooled using a random effects model. The main outcome was the overall available worldwide incidence and prevalence of TAAs. The secondary outcomes were to evaluate the incidence of ruptured TAAs, differences in the location of these aneurysms (either ascending, arch or descending aorta) and differences in prevalence/incidence across different study designs. Twenty-two studies were included in the review and meta-analysis. The pooled incidence and prevalence of TAAs was 5.3 per 100,000 individuals/year (95% confidence interval [CI]: 3.0; 8.3) and 0.16% (95% CI: 0.12; 0.20), respectively. The pooled incidence of ruptured aneurysms was 1.6 per 100,000 individuals/year (95% CI: 1.3; 2.1). We found a significant difference of the prevalence in autopsy-only studies, which was 0.76% (95% CI: 0.47; 1.13) and the prevalence of TAAs dropped down to 0.07% (95% CI: 0.05;0.11) when these studies were excluded from the overall analysis. The current epidemiologic information provided serve as a base for future public-health decisions. The lack of well-design population-base studies and the limitations encountered serve as calling for future research in this field.

Atherosclerosis: The cost of illness in Portugal.

INTRODUCTION AND OBJECTIVES: Cardiovascular disease is the leading cause of death in Portugal and atherosclerosis is the most common underlying pathophysiological process. The aim of this study was to quantify the economic impact of atherosclerosis in Portugal by estimating disease-related costs. METHODS: Costs were estimated based on a prevalence approach and following a societal perspective. Three national epidemiological sources were used to estimate the prevalence of the main clinical manifestations of atherosclerosis. The annual costs of atherosclerosis included both direct costs (resource consumption) and indirect costs (impact on population productivity). These costs were estimated for 2016, based on data from the Hospital Morbidity Database, the health care database (SIARS) of the Regional Health Administration of Lisbon and Tagus Valley including real-world data from primary care, the 2014 National Health Interview Survey, and expert opinion. RESULTS: The total cost of atherosclerosis in 2016 reached 1.9 billion euros (58% and 42% of which was direct and indirect costs, respectively). Most of the direct costs were associated with primary care (55%), followed by hospital outpatient care (27%) and hospitalizations (18%). Indirect costs were mainly driven by early exit from the labor force (91%). CONCLUSIONS: Atherosclerosis has a major economic impact, being responsible for health expenditure equivalent to 1% of Portuguese gross domestic product and 11% of current health expenditure in 2016.

The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence.

Management of asymptomatic carotid disease continues to challenge medical practice and present evidence is often conflicting. Stroke is a significant burden in Public Health and 11% to 15% appear as first neurologic event associated with asymptomatic carotid stenosis. Randomized trials provided support for Guidelines and Recommendations to intervene on asymptomatic stenosis, but at a known cost of a high number of unnecessary operations. Conflicting evidence from natural history studies and the widespread use of proper medical management including risk factors control, lowering-lipid drugs and strict control of arterial hypertension have reduced the incidence of strokes associated to asymptomatic carotid disease challenging established practice. Need to identify vulnerable lesions prone to develop thromboembolic brain events and also vulnerable patients at a higher risk of stroke is necessary and essential to further improve effectiveness of our interventions. After review of published literature on natural history of asymptomatic carotid stenosis, diagnostic methods to identify plaque vulnerability and present-day results of both endarterectomy and stenting, a strategy for management of asymptomatic carotid stenosis is suggested aiming to reduce unnecessary interventions and effectively contribute to stroke prevention.

Synchronous and Metachronous Thoracic Aortic Aneurysms in Patients With Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis.

Background The prevalence of thoracic aortic aneurysms (TAA) in patients with known abdominal aortic aneurysms (AAA) is not well known and understudied. Our aim was to conduct a systematic review and meta-analysis of the overall prevalence of synchronous and metachronous TAA (SM-TAA) in patients with a known AAA and to understand the characteristics of this sub-population. Methods and Results We searched MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) from inception to November 2019 for all population-based studies reporting on the prevalence of SM-TAAs in a cohort of patients with AAA. Article screening and data extraction were performed by 2 authors and data were pooled using a random-effects model of proportions using Freeman-Tukey double arcsine transformation. The main outcome was the prevalence of SM-TAAs in patients with AAAs. Secondary outcomes were the prevalence of synchronous TAAs, metachronous TAAs, prevalence of TAAs in patients with AAA according to the anatomic location (ascending, arch, and descending) and the differences in prevalence of these aneurysms according to sex and risk factors. Six studies were included. The pooled-prevalence of SM-TAA in AAA patients was 19.2% (95% CI, 12.3-27.3). Results revealed that 15.2% (95% CI, 7.1-25.6) of men and 30.7% (95% CI, 25.2-36.5) of women with AAA had an SM-TAA. Women with AAA had a 2-fold increased risk of having an SM-TAA than men (relative risk [RRs], 2.16; 95% CI, 1.32-3.55). Diabetes mellitus was associated with a 43% decreased risk of having SM-TAA (RRs, 0.57; 95% CI, 0.41-0.80). Conclusions Since a fifth of AAA patients will have an SM-TAA, routine screening of SM-TAA and their clinical impact should be more thoroughly studied in patients with known AAA.