Trends in Hospital Admissions, Operative Approaches, and Mortality Related to Abdominal Aortic Aneurysms in England Between 1998 and 2020.

OBJECTIVE: To assess trends in abdominal aortic aneurysm (AAA) hospital admissions, interventions, and aneurysm related mortality in England, and to examine the impact of endovascular repair on mortality for the years 1998 - 2020. METHODS: Hospital admission and operative approach (endovascular aortic aneurysm repair, or open surgical repair [OSR]) using Hospital Episodes Statistics (HES), and aneurysm related mortality data from the Office for National Statistics for England standardised to the 2013 European Standard Population, were analysed using linear regression and Joinpoint regression analyses. Aneurysm related mortality was compared between the pre-endovascular era (1998 - 2010) and the endovascular era (2011 - 2019). RESULTS: A declining trend in hospital admission incidence was observed, mainly due to a decline in ruptured admissions from 34.6 per 100 000 (95% confidence interval [CI] 33.5 - 35.6) to 13.5 per 100 000 (95% CI 12.9 - 14.2; ßi = -1.04, r2 = .97, p < .001). Operative interventions have been declining over the last 23 years mainly due to the statistically significant decline in open procedures (41.2 per 100 000 in 2000 [95% CI 40 - 42.3] to 9.6 per 100 000 [95% CI 9.1 - 10.1]; ßi = -1.92, r2 = .95; p < .001). There was an increasing trend toward endovascular procedures (5.8 per 100 000 [95% CI 5.3 - 6.2] in 2006 to 16.9 per 100 000 [95% CI 16.2 - 17.5] in 2020; ßi = .82, r2 = .30, p = .040). Reductions in aneurysm related mortality due to AAAs were observed for males and females, irrespective of age and rupture status. CONCLUSION: A significant decrease in hospital admissions for AAAs was observed over the last 23 years in England, paralleled by a shift toward endovascular repair and a decline in OSR. Declines in aneurysm related mortality were observed overall, and in the endovascular era irrespective of age, sex, and rupture status.

Trends in Thoracic Aortic Aneurysm Hospital Admissions, Interventions, and Mortality in England between 1998 and 2020: An Observational Study.

OBJECTIVE: To assess trends in thoracic aortic aneurysm (TAA) hospital admissions, interventions, and aneurysm related mortality (ARM) in England, and examine the impact of endovascular repair on mortality for the years 1998 to 2020. METHODS: Hospital admission and operative approach (thoracic endovascular aortic repair, [TEVAR] or open surgical repair) using Hospital Episodes Statistics, and ARM data from the Office for National Statistics for England standardised to the 2013 European Standard Population were analysed using linear regression and Joinpoint regression analyses. ARM was compared between the pre-endovascular era (1998 - 2008) and the endovascular era (2009 - 2019). RESULTS: A rising trend in hospital admission incidence has been observed, mainly due non-ruptured admissions (4.11 per 100 000 in 1998; 95% confidence interval (CI) 3.71 - 4.50 to 12.61 per 100 000 in 2020; 95% CI 12.00 - 13.21 in 2020; r2 = .98; p < .001). Operative interventions increased mainly due to an increase in TEVAR (2.15 per 100 000; 95% CI 1.91 - 2.41 in 2020 vs. 0.26 per 100 000; 95% CI 0.16 - 0.36 in 2006; r2 = .90; p < .001). Reductions in ARM from TAA were observed for males and females, irrespective of age and rupture status. The greatest reduction in ARM in the endovascular era was observed in females aged > 80 years with ruptured disease (15.26 deaths per 100 000 vs. 9.50 deaths per 100 000; p < .001). CONCLUSION: A significant increase in hospital admissions for non-ruptured TAA has been observed in the last 23 years in England, paralleled by a shift towards endovascular repair, and significant declining trends in ARM, irrespective of sex and age. The significant reductions in age standardised death rates from ruptured and non-ruptured TAA in the endovascular era, particularly for females aged > 80 years with ruptured disease, affirm the positive impact of an endovascular approach to TAA.

Location of Reentry Tears Affects False Lumen Thrombosis in Aortic Dissection Following TEVAR.

Purpose: To report a study that assesses the influence of the distance between the distal end of a thoracic stent-graft and the first reentry tear (SG-FRT) on the progression of false lumen (FL) thrombosis in patients who underwent thoracic endovascular aortic repair (TEVAR). Materials and Methods: Three patient-specific geometrical models were reconstructed from postoperative computed tomography scans. Two additional models were created by artificially changing the SG-FRT distance in patients 1 and 2. In all 5 models, computational fluid dynamics simulations coupled with thrombus formation modeling were performed at physiological flow conditions. Predicted FL thrombosis was compared to follow-up scans. Results: There was reduced false lumen flow and low time-averaged wall shear stress (TAWSS) in patients with large SG-FRT distances. Predicted thrombus formation and growth were consistent with follow-up scans for all patients. Reducing the SG-FRT distance by 30 mm in patient 1 increased the flow and time-averaged wall shear stress in the upper abdominal FL, reducing the thrombus volume by 9.6%. Increasing the SG-FRT distance in patient 2 resulted in faster thoracic thrombosis and increased total thrombus volume. Conclusion: The location of reentry tears can influence the progression of FL thrombosis following TEVAR. The more distal the reentry tear in the aorta the more likely it is that FL thrombosis will occur. Hence, the distal landing zone of the stent-graft should be chosen carefully to ensure a sufficient SG-FRT distance.

Imaging vulnerable plaques by targeting inflammation in atherosclerosis using fluorescent-labeled dual-ligand microparticles of iron oxide and magnetic resonance imaging.

OBJECTIVE: Identification of patients with high-risk asymptomatic carotid plaques remains an elusive but essential step in stroke prevention. Inflammation is a key process in plaque destabilization and a prelude to clinical sequelae. There are currently no clinical imaging tools to assess the inflammatory activity within plaques. This study characterized inflammation in atherosclerosis using dual-targeted microparticles of iron oxide (DT-MPIO) as a magnetic resonance imaging (MRI) probe. METHODS: DT-MPIO were used to detect and characterize inflammatory markers, vascular cell adhesion molecule 1 (VCAM-1). and P-selectin on (1) tumor necrosis factor-α-treated cells by immunocytochemistry and (2) aortic root plaques of apolipoprotein-E deficient mice by in vivo MRI. Furthermore, apolipoprotein E-deficient mice with focal carotid plaques of different phenotypes were developed by means of periarterial cuff placement to allow in vivo molecular MRI using these probes. The association between biomarkers and the magnetic resonance signal in different contrast groups was assessed longitudinally in these models. RESULTS: Immunocytochemistry confirmed specificity and efficacy of DT-MPIO to VCAM-1 and P-selectin. Using this in vivo molecular MRI strategy, we demonstrated (1) the DT-MPIO-induced magnetic resonance signal tracked with VCAM-1 (r = 0.69; P = .014), P-selectin (r = 0.65; P = .022), and macrophage content (r = 0.59; P = .045) within aortic root plaques and (2) high-risk inflamed plaques were distinguished from noninflamed plaques in the murine carotid artery within a practical clinical imaging time frame. CONCLUSIONS: These molecular MRI probes constitute a novel imaging tool for in vivo characterization of plaque vulnerability and inflammatory activity in atherosclerosis. Further development and translation into the clinical arena will facilitate more accurate risk stratification in carotid atherosclerotic disease in the future.

Staged open, endovascular, and hybrid repair of concomitant mycotic aneurysms.

Primary mycotic aneurysms of the aorta are a rare but life-threatening condition. A 59-year-old woman developed a back abscess secondary to an insect bite. A computed tomography scan revealed 3 concomitant mycotic aneurysms, including a rupture. Staged repair was undertaken: immediate open repair for contained rupture of a type IV thoracoabdominal aortic aneurysm, followed by endovascular repair of a descending thoracic aneurysm 3 weeks later and finally an aortic arch hybrid repair of a left subclavian artery aneurysm 16 months later. She remains well postoperatively. There is currently no consensus on the timing of repair or modality of treatment of mycotic aneurysms. Each patient should be treated individually based on aneurysm location, rupture, and comorbidities, as shown by this case.

A numerical study of the effect of thrombus breakdown on predicted thrombus formation and growth.

Thrombosis is a complex biological process which involves many biochemical reactions and is influenced by blood flow. Various computational models have been developed to simulate natural thrombosis in diseases such as aortic dissection (AD), and device-induced thrombosis in blood-contacting biomedical devices. While most hemodynamics-based models consider the role of low shear stress in the initiation and growth of thrombus, they often ignore the effect of thrombus breakdown induced by elevated shear stress. In this study, a new shear stress-induced thrombus breakdown function is proposed and implemented in our previously published thrombosis model. The performance of the refined model is assessed by quantitative comparison with experimental data on thrombus formation in a backward-facing step geometry, and qualitative comparison with in vivo data obtained from an AD patient. Our results show that incorporating thrombus breakdown improves accuracy in predicted thrombus volume and captures the same pattern of thrombus evolution as measured experimentally and in vivo. In the backward-facing step geometry, thrombus breakdown impedes growth over the step and downstream, allowing a stable thrombus to be reached more quickly. Moreover, the predicted thrombus volume, height and length are in better agreement with the experimental measurements compared to the original model which does not consider thrombus breakdown. In the patient-specific AD, the refined model outperforms the original model in predicting the extent and location of thrombosis. In conclusion, the effect of thrombus breakdown is not negligible and should be included in computational models of thrombosis.

Initial findings and potential applicability of computational simulation of the aorta in acute type B dissection.

OBJECTIVE: Type B aortic dissection can be acutely complicated by rapid expansion, rupture, and malperfusion syndromes. Short-term adverse outcomes are associated with failure of the false lumen to thrombose. The reasons behind false lumen patency are poorly understood, and the objective of this pilot study was to use computational fluid dynamics reconstructions of aortic dissection cases to analyze the effect of aortic and primary tear morphology on flow characteristics and clinical outcomes in patients with acute type B dissections. METHODS: Three-dimensional patient-specific aortic dissection geometry was reconstructed from computed tomography scans of four patients presenting with acute type B aortic dissection and a further patient with sequential follow-up scans. The cases were selected based on their clinical presentation. Two were complicated by acute malperfusion that required emergency intervention. Three patients were uncomplicated and were managed conservatively. The patient-specific aortic models were used in computational simulations to assess the effect of aortic tear morphology on various parameters including flow, velocity, shear stress, and turbulence. RESULTS: Pulsatile flow simulation results showed that flow rate into the false lumen was dependent on both the size and position of the primary tear. Linear regression analysis demonstrated a significant relationship between percentage flow entering the false lumen and the size of the primary entry tear and an inverse relationship between false lumen flow and the site of the entry tear. Subjects complicated by malperfusion had larger-dimension entry tears than the uncomplicated cases (93% and 82% compared with 32% and 55%, respectively). Blood flow, wall shear stress, and turbulence levels varied significantly between subjects depending on aortic geometry. Highest wall shear stress (>7 Pa) was located at the tear edge, and progression of false lumen thrombosis was associated with prolonged particle residence times. CONCLUSIONS: Results obtained from this preliminary work suggest that aortic morphology and primary entry tear size and position exert significant effects on flow and other hemodynamic parameters in the dissected aorta in this preliminary work. Blood flow into the false lumen increases with increasing tear size and proximal location. Morphologic analysis coupled with computational fluid dynamic modeling may be useful in predicting acute type B dissection behavior allowing for selection of proper treatment modalities, and further confirmatory studies are warranted.

Salvage antegrade visceral revascularization and antegrade aortic stenting for type I and III endoleaks after fenestrated juxtarenal aneurysm repair.

A 73-year-old man developed type I and III endoleaks from a fractured right renal stent with downward migration of a fenestrated endograft, 6 years after endovascular repair of a juxtarenal aneurysm. Endovascular treatment attempts were unsuccessful. He underwent aortic debranching and antegrade visceral artery revascularization via a left thoracolaparotomy incision and an extraperitoneal approach to the visceral aorta. An antegrade aortic stent covered the endoleak, with technical and clinical success at 9 months. Failure of complex endografts presents particular problems, potentially not amenable to totally endovascular repair. Continued surveillance is mandated as late, asymptomatic sac expansion can occur.

Shear-driven modelling of thrombus formation in type B aortic dissection.

Background: Type B aortic dissection (TBAD) is a dangerous pathological condition with a high mortality rate. TBAD is initiated by an intimal tear that allows blood to flow between the aortic wall layers, causing them to separate. As a result, alongside the original aorta (true lumen), a false lumen (FL) develops. TBAD compromises the whole cardiovascular system, in the worst case resulting in complete aortic rupture. Clinical studies have shown that dilation and rupture of the FL are related to the failure of the FL to thrombose. Complete FL thrombosis has been found to improve the clinical outcomes of patients with chronic TBAD and is the desired outcome of any treatment. Partial FL thrombosis has been associated with late dissection-related deaths and the requirement for re-intervention, thus the level of FL thrombosis is dominant in classifying the risk of TBAD patients. Therefore, it is important to investigate and understand under which conditions complete thrombosis of the FL occurs. Method: Local FL hemodynamics play an essential role in thrombus formation and growth. In this study, we developed a simplified phenomenological model to predict FL thrombosis in TBAD under physiological flow conditions. Based on an existing shear-driven thrombosis model, a comprehensive model reduction study was performed to improve computational efficiency. The reduced model has been implemented in Ansys CFX and applied to a TBAD case following thoracic endovascular aortic repair (TEVAR) to test the model. Predicted thrombus formation based on post-TEVAR geometry at 1-month was compared to actual thrombus formation observed on a 3-year follow-up CT scan. Results: The predicted FL status is in excellent agreement with the 3-year follow-up scan, both in terms of thrombus location and total volume, thus validating the new model. The computational cost of the new model is significantly lower than the previous thrombus model, with an approximate 65% reduction in computational time. Such improvement means the new model is a significant step towards clinical applicability. Conclusion: The thrombosis model developed in this study is accurate and efficient at predicting FL thrombosis based on patient-specific data, and may assist clinicians in choosing individualized treatments in the future.

The changing management of primary mycotic aortic aneurysms.

OBJECTIVE: The objective of this study is to examine contemporary management of primary mycotic aortic aneurysms in a single center. We have previously reported the management of mycotic aortic aneurysms in 15 patients between 1991 and 2001, and we hypothesized that management would change in the light of the evolution of endovascular aortic repair. METHODS: A review of a prospectively collected database (2002-2009) of all patients presenting with mycotic aneurysms. RESULTS: A total of 19 aneurysms were identified in 17 patients (12 men, 5 women) with a median age of 66.2 years (range, 49-82 years). All were symptomatic, and nine had contained rupture. There were five infrarenal, two juxtarenal, three Crawford type III, four type IV thoracoabdominal aortic aneurysms, and five descending thoracic aneurysms in the series. All thoracic aneurysms were excluded by thoracic endovascular aneurysm repair. Two patients underwent visceral hybrid endografting for type III thoracic aortic aneurysm; the third was treated with open repair. Four patients underwent open type IV repair. Two of the infrarenal aneurysms were treated with bifurcated endovascular aneurysm repair, and the other three and both juxtarenals with open repair with in situ reconstruction. There were three early (17.6%) and three late deaths (17.6%). The median follow-up was 30.5 months (range, 1-102 months). CONCLUSIONS: The results of the latest series show that open surgery is still required in many cases. The introduction of endovascular techniques in the exclusion of mycotic aneurysms can be accomplished with acceptable results, and endovascular treatment has increased the therapeutic options for a difficult condition.

A computational model for false lumen thrombosis in type B aortic dissection following thoracic endovascular repair.

Thoracic endovascular repair (TEVAR) has recently been established as the preferred treatment option for complicated type B dissection. This procedure involves covering the primary entry tear to stimulate aortic remodelling and promote false lumen thrombosis thereby restoring true lumen flow. However, complications associated with incomplete false lumen thrombosis, such as aortic dilatation and stent graft induced new entry tears, can arise after TEVAR. This study presents the application and validation of a recently developed mathematical model for patient-specific prediction of thrombus formation and growth under physiologically realistic flow conditions. The model predicts thrombosis through the evaluation of shear rates, fluid residence time and platelet distribution, based on convection-diffusion-reaction transport equations. The model was applied to 3 type B aortic dissection patients: two TEVAR cases showing complete and incomplete false lumen thrombosis respectively, and one medically treated dissection with no signs of thrombosis. Predicted thrombus growth over time was validated against follow-up CT scans, showing good agreement with in vivo data in all cases with a maximum difference between predicted and measured false lumen reduction below 8%. Our results demonstrate that TEVAR-induced thrombus formation in type B aortic dissection can be predicted based on patient-specific anatomy and physiologically realistic boundary conditions. Our model can be used to identify anatomical or stent graft related factors that are associated with incomplete false lumen thrombosis following TEVAR, which may help clinicians develop personalised treatment plans for dissection patients in the future.

Two-Vessel Branched Stent Graft for Severely Angulated Aortic Arch Aneurysm in a Jehovah's Witness.

Aneurysmal disease involving the origins of supra aortic vessels often requires complex open and/or endovascular repair that is not only associated with significant risk of mortality and morbidity but also often with perioperative blood loss requiring transfusion. We report a successful repair of a large thoracic aortic aneurysm (TAA) involving the aortic arch with a custom-made Bolton Relay 2-vessel branched thoracic aortic endograft in a 42-year-old Jehovah's Witness who would otherwise be very unlikely to survive an open repair. Branched thoracic aortic endografting offers a potentially safe, minimally invasive, and effective alternative for TAA disease involving the supra-aortic arteries, especially in patients who are at high risk of open surgery.

MRI detection of endothelial cell inflammation using targeted superparamagnetic particles of iron oxide (SPIO).

BACKGROUND: There is currently no clinical imaging technique available to assess the degree of inflammation associated with atherosclerotic plaques. This study aims to develop targeted superparamagnetic particles of iron oxide (SPIO) as a magnetic resonance imaging (MRI) probe for detecting inflamed endothelial cells. METHODS: The in vitro study consists of the characterisation and detection of inflammatory markers on activated endothelial cells by immunocytochemistry and MRI using biotinylated anti-P-selectin and anti-VCAM-1 (vascular cell adhesion molecule 1) antibody and streptavidin conjugated SPIO. RESULTS: Established an in vitro cellular model of endothelial inflammation induced with TNF-α (tumor necrosis factor alpha). Inflammation of endothelial cells was confirmed with both immunocytochemistry and MRI. These results revealed both a temporal and dose dependent expression of the inflammatory markers, P-selectin and VCAM-1, on exposure to TNF-α. CONCLUSION: This study has demonstrated the development of an in vitro model to characterise and detect inflamed endothelial cells by immunocytochemistry and MRI. This will allow the future development of contrast agents and protocols for imaging vascular inflammation in atherosclerosis. This work may form the basis for a translational study to provide clinicians with a novel tool for the in vivo assessment of atherosclerosis.

Predicting false lumen thrombosis in patient-specific models of aortic dissection.

Aortic dissection causes splitting of the aortic wall layers, allowing blood to enter a 'false lumen' (FL). For type B dissection, a significant predictor of patient outcomes is patency or thrombosis of the FL. Yet, no methods are currently available to assess the chances of FL thrombosis. In this study, we present a new computational model that is capable of predicting thrombus formation, growth and its effects on blood flow under physiological conditions. Predictions of thrombus formation and growth are based on fluid shear rate, residence time and platelet distribution, which are evaluated through convection-diffusion-reaction transport equations. The model is applied to a patient-specific type B dissection for which multiple follow-up scans are available. The predicted thrombus formation and growth patterns are in good qualitative agreement with clinical data, demonstrating the potential applicability of the model in predicting FL thrombosis for individual patients. Our results show that the extent and location of thrombosis are strongly influenced by aortic dissection geometry that may change over time. The high computational efficiency of our model makes it feasible for clinical applications. By predicting which aortic dissection patient is more likely to develop FL thrombosis, the model has great potential to be used as part of a clinical decision-making tool to assess the need for early endovascular intervention for individual dissection patients.

Geometric and flow features of type B aortic dissection: initial findings and comparison of medically treated and stented cases.

Uncomplicated acute type B aortic dissections are usually treated medically, but they can become acutely complicated by rapid expansion, rupture and malperfusion syndromes and in the longer term by chronic dilatation and aortic aneurysm formation. The objective of this study is to use computational fluid dynamics reconstructions of type B aortic dissections to compare geometric and haemodynamic factors between the cases selected for medical treatment and the cases selected for thoracic endovascular aortic repair (TEVAR), and to examine whether any of these factors are associated with the outcome of the medically treated group. This study includes eight type B dissection cases, with four in each group. Aortic flow analyses were carried out based on patient-specific anatomy at initial presentation before treatment. Comparisons between the two groups show that the false lumen to true lumen volume ratio is considerably higher in patients selected for TEVAR. Results from the four medically treated cases indicate that the size of the primary entry tear is the key determinant of the false lumen flow rate, which may influence the long-term outcome of medically treated patients. Potential relations between flow related parameters based on initial anatomy and subsequent anatomical changes in the medically treatment group were examined. Our initial findings based on the limited cases are that high relative residence time is a strong predictor of subsequent false lumen thrombosis, whereas pressure difference between the true and false lumen as well as the location of the largest pressure difference may be associated with the likelihood of subsequent aortic expansion.

Investigation and treatment of a complicated inflammatory aortoiliac aneurysm.

Inflammatory abdominal aortic aneurysms (IAAAs) account for 5% to 10% of all abdominal aortic aneurysms, occurring primarily in males. Their true etiology is unknown. Symptoms and signs of IAAA are so variable that they present to a wide range of specialties. There is debate in the literature whether IAAA is a manifestation of systemic autoimmune disease. We describe the case of a young female patient with complicated inflammatory aortoiliac aneurysmal disease, illustrating diagnostic and treatment challenges that remain. Our patient had a positive autoantibody screen, raised erythrocyte sedimentation rate, positive enzyme-linked immunosorbent spot test, and saccular aneurysms, including infective and inflammatory etiologies in her differential diagnosis. Early diagnosis is crucial to limit disease progression, morbidity, and mortality. Medical management is important to address the underlying disease process, but a combination of endovascular and open surgical intervention is often necessary for definitive treatment. Available evidence offers plausibility for benefit of endovascular intervention over open repair.

Association of raised titres of antibodies to Chlamydia pneumoniae with a history of pre-eclampsia.

OBJECTIVE: To establish the prevalence of Chlamydia pneumoniae (C. pneumoniae) infection in a pregnant UK population and to investigate whether C. pneumoniae infection is more common in women with a previous history of pre-eclampsia. DESIGN: Prospective study. SETTING: Academic Hospital. POPULATION: Ninety-one pregnant women (54 parous and 37 nulliparous) at 16-22 weeks of gestation were studied. Of the parous women, 32 had a previous history of pre-eclampsia. METHODS: Peripheral blood was drawn for C. pneumoniae antibodies between 16-22 and 28-40 weeks of gestation. C. pneumoniae antibodies were measured using a solid-phase enzyme immunoassay. According to pregnancy outcome, women were categorised into normal, gestational hypertension and pre-eclampsia groups. MAIN OUTCOME MEASURES: Serum levels of IgG, IgA and IgM C. pneumoniae antibodies. RESULTS: Prevalence of seropositivity to C. pneumoniae was 77%. Parous women had significantly higher levels of IgA and IgM C. pneumoniae antibodies than nulliparous women (P < 0.04). Parous women with previous pre-eclampsia were found to have higher levels of antibodies than parous women with a normal obstetric history (P< or = 0.003). There was no difference in the antibody levels in women with different pregnancy outcomes. CONCLUSIONS: The longitudinal data do not indicate an association between C. pneumoniae infection and pre-eclampsia. However, the subgroup analysis of parous women demonstrated raised C. pneumoniae antibodies in the women with previous pre-eclampsia, and therefore suggests that there may be an association between C. pneumoniae and the disease in this group.