Screening Men and Women above the Age of 50 Years for Abdominal Aortic Aneurysm: A Pilot Study in an Upper Middle Income Country.

OBJECTIVE: Screening for abdominal aortic aneurysm (AAA) is recommended in high risk populations based on local conditions. Differences in lifestyle and risk factors between countries with different income status make risk stratification based on geographic location necessary. The majority of epidemiological studies on AAA have reported data from high income countries. The aim of this study was to explore the prevalence and risk factors for AAA in an upper middle income country in Eastern Europe. METHODS: A pilot screening project for AAA, supported by a mass media campaign, was conducted in 2023 in seven cities in Serbia. Ultrasound evaluation of the abdominal aorta was performed by a registered vascular surgeon on individuals who agreed to participate. Participants who attended screening completed a questionnaire on demographic and clinical information. To assess risk factors for AAA, univariable logistic regression analysis was performed to compute the odds ratio (OR) with 95% confidence interval (CI). Multivariable logistic regression was subsequently performed with adjustments for sex, age, family history of AAA, and other relevant factors. RESULTS: A total of 4 046 participants (51.2% male and 48.8% female; mean age 68.8 ± 7.6 years) responded to the campaign. An aneurysm was found in 195 (4.8%) screened individuals (8.2% of men and 1.3% of women). In males aged 50 - 64 years, the prevalence of AAA was 5.4%. Male sex, older age, family history of AAA, being a smoker or ex-smoker, being overweight, and alcohol consumption were predictors of AAA in the univariable analysis. After adjustments in the multivariable analysis, male sex (OR 8.04, 95% CI 4.87 - 13.28), older age (OR 1.04, 95% CI 1.02 - 1.07), positive family history (OR 2.47, 95% CI 1.61 - 3.78), smoker status (OR 3.10, 95% CI 2.10 - 4.59), ex-smoker status (OR 2.13, 95% CI 1.39 - 3.27), and being overweight (OR 1.85, 95% CI 1.25 - 2.74) were independent risk factors for AAA. CONCLUSION: The prevalence of AAA has not been reduced in all countries, and screening strategies might be changed based on local epidemiological data. The results of this pilot study underline the importance of exploring the prevalence of AAA in populations with a high prevalence of smoking.

The influence of gender on 30-day adverse clinical outcomes in patients undergoing carotid surgery.

BACKGROUND: We aimed to further evaluate sex differences of perioperative and 30-day complications after carotid surgery in patients with both asymptomatic and symptomatic carotid artery stenosis. METHODS: This was a single-center prospective cohort study including 2013 consecutive patients, who were treated surgically due to extracranial carotid artery stenosis and prospectively followed. Patients who underwent carotid artery stenting and who were treated conservatively were excluded. The primary endpoints for this study were hospital stroke/transitory ischemic attack (TIA) and overall survival rates. Secondary outcomes included all other hospital adverse events, 30-day stroke/TIA, and 30-day mortality rates. RESULTS: Hospital mortality was higher in female patients with symptomatic carotid stenosis (3% vs. 0.5%, P=0.018). Bleeding requiring re-intervention occurred more often in female patients with both asymptomatic (1.5% vs. 0.4%, P=0.045) and symptomatic carotid stenosis (2.4% vs. 0.2%, P=0.022). 30-day stroke/TIA and mortality rates were higher in female patients with both asymptomatic (stroke/TIA 4.4% vs. 2.5%, P=0.041; mortality 3.3% vs. 1.6%, P=0.046) and symptomatic carotid stenosis (stroke/TIA 8.3% vs. 4.2%, P=0.040; mortality 4.1% vs. 0.7%, P=0.006). After adjusting for all confounding factors, female gender remained an important predicting factor for 30-day stroke/TIA in asymptomatic (OR=1.4, 95%CI 1.0-4.7, P=0.041) and symptomatic patients (OR=1.7, 95%CI 1.1-5.3, P=0.040), as well as for 30-day all-cause mortality in patients with asymptomatic (OR=1.5, 95%CI 1.1-4.1, P=0.030) and symptomatic carotid artery disease (OR=1.2, 95%CI 1.0-5.2, P=0.048). CONCLUSIONS: Female gender is important predicting factor for stroke/TIA and all-cause mortality, both perioperative and during the first 30 days after carotid surgery.

Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center.

BACKGROUND: The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma. METHODS: This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience. RESULTS: Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009). CONCLUSIONS: Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement.

Arterial thoracic outlet syndrome: a 30-year experience in a high-volume referral center.

BACKGROUND: The purpose of this study was to assess the clinical presentation and contemporary management of arterial thoracic outlet syndrome (TOS) in high-volume referral center. METHODS: We conducted a retrospective review of a prospectively maintained database of patients with TOS of any etiology between January 1st 1990 and 2021. Supra-, or combined supra-/infraclavicular approaches have been used for decompression/vascular reconstructions. The group was divided into two equal time periods: period 1 (1990-2006, N.=27) and period 2 (2006-2021, N.=36). RESULTS: Sixty-three consecutive patients underwent surgical treatment due to arterial TOS. Period 2 had more patients who were asymptomatic (N.=16, 44.4% vs. N.=0, 0%, P<0.001) and those presenting with critical hand ischemia (N.=12, 33.3% vs. N.=0, 0%, P=0.01), while acute limb ischemia was more common in period 1 (N.=16, 59.2% vs. N.=5, 13.9%, P<0.001). SA compression without lesion was more common in period 2 (N.=16, 44.4% vs. N.=0, 0%, P<0.001), while SA intimal damage with mural thrombus formation was more common in the period 1 (N.=12, 44.4% vs. N.=1, 2.7%, P<0.001). Decompression as an isolated procedure was performed in 25.4% (N.=16) of all asymptomatic patients, while combined decompressive and vascular procedure in 71.4% (N.=45) of patients. The most common postoperative complication was pneumothorax (N.=7, 11.1%). CONCLUSIONS: The supraclavicular approach with its modifications provides adequate decompression and allows also repair or reconstruction of the SA, as well as complete additional revascularization of the upper extremity without the need for further patient repositioning. While treatment methods and early outcomes have not changed significantly over time, there has been a trend towards different clinical and SA pathomorphological presentation.

Correlation Between Proteolytic Activity and Abdominal Aortic Aneurysm Wall Morphology with Intraluminal Thrombus Volume.

BACKGROUND: The aim of this study was to examine the influence of intraluminal thrombus (ILT) volume on the level of proteolytic activity and the content of abdominal aortic aneurysm (AAA) wall. METHODS: The research was designed as a cross-sectional study at the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia in the period from April 2017 to February 2018. During this period, a total of 155 patients with asymptomatic AAA underwent open surgical treatment and 50 were included in the study based on inclusion and exclusion criteria. Before surgery, patients included in the study were examined by MRI. During the operation, samples of ILT and AAA wall were taken for biochemical analysis. RESULTS: A statistically significant correlation was found between the volume of the ILT and largest AAA diameter (ρ = 0.56; P < 0.001). The correlation of the ILT volume on the anterior wall and the concentration of MMP-9, MMP-2 and NE/ELA in the wall did not find statistical significance. Also, no statistically significant association was found between the volume of ILT and the concentration of ECM proteins (collagen type 3, elastin, proteoglycan) in the corresponding part of the wall. The association of ILT volume with MDA was also of no statistical significance. There was a positive statistical significance found in correlation of volume of ILT and catalase activity in the wall of AAA (ρ = 0.28, P = 0.049). CONCLUSIONS: The volume of ILT in the aneurysmal sac seemed not to affect the level of proteolytic activity and the content of the aneurysm wall. However, a positive correlation was found between the ILT and the catalase activity. The effect of ILT on the aneurysm wall and its role in the progression of aneurysmal disease should be examined in future studies.

Influence of perioperative risk factors on the development of transmural colonic ischemia after open repair of ruptured abdominal aortic aneurysm.

BACKGROUND: Development of colonic ischemia (CI) after ruptured abdominal aortic aneurysm (RAAA) treatment is a lethal complication with perioperative mortality reported to be high as 50%. Therefore, the main goal of this study was to identify pre-, intra- and postoperative risk factors associated with CI in patients undergoing open repair (OR) due to RAAA, that might help to select patients who are more prone to develop CI. METHODS: This was a single-center prospective cohort study on patients with RAAA undergoing OR between January 1st 2018 and July 1st 2019, at the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia. During this period 89 patients were treated due to RAAA and all were included in the study. The primary endpoint was grade III CI, or transmural necrosis, diagnosed by laparotomy. RESULTS: Out of 89 patients operated due to RAAA, CI was diagnosed in 14 (15.73%). During the operation, patients with CI had a longer duration of hypotension (42.86±35.82 vs. 24.13±23.48, P=0.021) and more common significant hypotension (54.54% vs. 14.66%, P=0.024). In the postoperative course, patients with CI had more common signs of abdominal compartment syndrome (71.42% vs. 25.33%, P=0.001) and higher mortality rate (78.57% vs 29.33%, P=0.001). The univariate regression model showed that one of the most significant factors that were associated with CI were age higher than 75 years, significant hypotension lasting more than one hour, organ lesion, development of abdominal compartment syndrome and higher potassium values on third and fourth quartile. CONCLUSIONS: Grade III colon ischemia (transmural) remains the important cause of mortality after ruptured abdominal aortic aneurysm repair. We identified pre- and intraoperative and postoperative risk factors that could improve the selection of patients for primary open abdomen treatment or early exploratory laparotomy in order to prevent or timely diagnose colon ischemia.

Thoracic Endovascular Aortic Repair Practice in 13 Countries: A Report From VASCUNET and the International Consortium of Vascular Registries.

OBJECTIVE: To assess practice patterns and short-term outcome after thoracic endovascular aortic repair (TEVAR), based on an international vascular registry collaboration. SUMMARY BACKGROUND DATA: TEVAR has become the primary surgical treatment modality for descending aortic pathologies, and has expanded to new patient cohorts, including the elderly. METHODS: Data on thoracic aortic aneurysms (TAA), type B aortic dissections (TBAD), and traumatic aortic injuries (TAI) treated with TEVAR from 2012 to 2016 were retrieved from registries and centers in 13 countries. RESULTS: Nine-thousand five-hundred eighteen TEVAR for TAA ( n = 4436), TBAD ( n = 3976) and TAI ( n = 1106) were included. The distribution of TEVAR procedures per pathology varied, with TAA repair constituting from 40% of TEVARs in the US to 72% in the UK ( P < 0.001).Mean intact TAA (iTAA) diameter varied from 59 (US) to 69 mm (Nancy, France) ( P < 0.001), 25.3% of patients having a diameter of <60 mm. Perioperative mortality after iTAA repair was 4.9%; combined mortality, stroke, paraplegia, and renal replacement therapy outcome was 12.8%. 18.6% of iTAA patients were ≥80 years old. Mortality was higher in this group (7.2%) than in patients <80 (3.8%) ( P < 0.001). After rTAA repair, perioperative mortality was 26.8%.Mortality was 9.7% after acute (within 14 days from onset of dissection) and 3.0% after chronic TBAD repair ( P < 0.001). Mortality after TAI was 7.8%, and depended on injury severity (grade IV (free rupture) 20.9%). CONCLUSIONS: This registry collaboration provides a unique platform to evaluate cross-border patterns of use and outcomes of TEVAR. A common core dataset is proposed, to achieve harmonization of registry-based quality outcome measures for TEVAR.

Hybrid repair of aortic arch with zone zero endografting-Case series with review of the literature.

INTRODUCTION: We present single-institution results of types I and II hybrid procedures for aortic arch disease with 30-day and long-term results and review of the literature. MATERIALS AND METHODS: This is a retrospective study of all patients that underwent zone 0 endografting and open bypass from ascending aorta to the arch vessels at our institution between January 2013 and 2020. The following data for the systematic review were extracted from eligible studies: 30-day/in-hospital mortality, stroke rate, spinal cord ischemia (SCI) rate, renal failure requiring dialysis, development of retrograde dissection, early (<30 days) types I and III endoleak, follow-up length, late (>30 days) endoleak, and late (>30 days) mortality. RESULTS: Twelve patients underwent hybrid aortic arch treatment in our institution. The most common aortic arch pathology was degenerative aortic aneurysm. The rate of retrograde dissection and SCI was 8.33%. Regarding the literature data, a total of 768 patients undergoing types I and II hybrid aortic arch debranching procedure. The pooled rate of 30-day/in-hospital mortality was 10.96% (95% confidence interval [CI], 8.21-14.06), SCI pooled rate was 2.91% (95% CI, 1.76%-4.33%), and retrograde dissection pooled rate was 3.22% (95% CI, 1.99-4.72). CONCLUSION: Hybrid arch techniques provide safe alternative to open repair with acceptable short- and midterm results.

Predictors of in-hospital mortality and complications in acute aortic occlusion: a comparative analysis of patients with embolism and in-situ thrombosis.

BACKGROUND: Acute aortic occlusion (AAO) represents potentially fatal acute vascular emergency that requires prompt diagnosis and intervention. Clinical condition of patients with AAO is frequently severely devastated when surgical intervention is questionable. Our objective was to retrospectively review our institutional experience with AAO and assess predictors of intrahospital mortality and morbidity. METHODS: This is a retrospective single-center cohort study with prospectively collected data between January 1, 2005 and January 1, 2018. The total number of 28 consecutive patients with AAO were included in our analysis. Patients with acute aortic thrombosis manifested by bilateral acute limb ischemia were divided in two groups based on potential caues of AAO (embolism or in-situ thrombosis) differentiated according to condition of aortoilical segment. RESULTS: We identified 28 patients with AAO. All of them underwent either aortobifemoral bypass (N.=20, 71%) or bilateral trans-femoral thrombectomy (N.=8, 29%). The overall in-hospital mortality was 36%. Factors that influenced in-hospital mortality were: paralysis (OR=4.41, 95% CI: 1.88-21.78) and higher lactate values on admission (OR=1.23, 95% CI: 1.09-1.83), postoperative development of severe acute kidney injury (OR=3.08, 95% CI: 1.42-14.66), hemodialysis (OR=10.74, 95% CI: 1.64-109.78) and bowel ischemia (OR=5.19, 95% CI: 1.58-55.63). CONCLUSIONS: Paralysis, higher lactate values, development of acute kidney injury, hemodialysis and bowel ischemia are predictors of worse outcome and may be used for risk stratification of patients with acute aortic occlusion and improve counseling patients and their families about expected postoperative outcomes. Patients with embolism and malignant disease have worse outcome; however, this should be tested in future studies on larger sample.

The TAXINOMISIS Project: A multidisciplinary approach for the development of a new risk stratification model for patients with asymptomatic carotid artery stenosis.

INTRODUCTION: Asymptomatic carotid artery stenosis (ACAS) may cause future stroke and therefore patients with ACAS require best medical treatment. Patients at high risk for stroke may opt for additional revascularization (either surgery or stenting) but the future stroke risk should outweigh the risk for peri/post-operative stroke/death. Current risk stratification for patients with ACAS is largely based on outdated randomized-controlled trials that lack the integration of improved medical therapies and risk factor control. Furthermore, recent circulating and imaging biomarkers for stroke have never been included in a risk stratification model. The TAXINOMISIS Project aims to develop a new risk stratification model for cerebrovascular complications in patients with ACAS and this will be tested through a prospective observational multicentre clinical trial performed in six major European vascular surgery centres. METHODS AND ANALYSIS: The risk stratification model will compromise clinical, circulating, plaque and imaging biomarkers. The prospective multicentre observational study will include 300 patients with 50%-99% ACAS. The primary endpoint is the three-year incidence of cerebrovascular complications. Biomarkers will be retrieved from plasma samples, brain MRI, carotid MRA and duplex ultrasound. The TAXINOMISIS Project will serve as a platform for the development of new computer tools that assess plaque progression based on radiology images and a lab-on-chip with genetic variants that could predict medication response in individual patients. CONCLUSION: Results from the TAXINOMISIS study could potentially improve future risk stratification in patients with ACAS to assist personalized evidence-based treatment decision-making.

Long-term Durability and Safety of Carotid Endarterectomy Closure Techniques.

BACKGROUND: Various techniques have been used for the execution of carotid endarterectomy; primary (PC), patch closure (CP) and eversion technique (ET).The superiority of any of them is still unproven. The aim of this study was to compare the long-term outcomes of each technique in terms of cerebrovascular event (CVE), restenosis, survival and major cardiac event (MACE). METHODS: Between 2007 and 2018, a retrospective analysis of prospectively recorded data from three European tertiary centers was undertaken including 1.357 patients. Demographics, comorbidities and medical treatment were analyzed in relation to long-term outcomes. Freedom from CVE, restenosis (> 70%), survival and MACE were estimated with Kaplan-Meier analysis curve. RESULTS: The mean age was 69.5 ± 8 (72% males;79% asymptomatic). 472 (35%) were treated with PC, 504 (37%) with CP and 381 (28%) with ET. Differences among groups were observed in age (P < 0.001), gender (P < 0.01), hypertension (P = 0.01), dyslipidemia (P < 0.001) and statin treatment (P < 0.001). The mean follow-up was 4.7 ± 3 years (median: 5 years). Seventy-three patients presented a CVE during 8 years of follow-up. The freedom from CVE including all techniques was 96% (SE 0.6%), 93% (SE 1%) and 89% (SE 1.6%), at 2, 5 and 8 years of follow-up, respectively, with no difference between groups (P .289). Freedom from restenosis was at 96% (SE 0.7%) and 89% (SE 5%) at 5 and 10 years, respectively, for all methods without differences. ET was associated with a higher mortality rate (P < 0.001) and MACE rate (P < 0.001). CONCLUSIONS: Excellent outcomes were achieved with all types of closure techniques with low rates of MACE and other adverse events during long-term follow-up after CEA.