BACKGROUND: The aim was to investigate the total prevalence of known and undiagnosed diabetes mellitus (DM), and the association of DM with perioperative complications following elective, infrarenal, open surgical (OSR) or endovascular (EVAR), Abdominal Aortic Aneurysm (AAA) repair.
METHODS: In this Norwegian prospective multicentre study, 877 patients underwent preoperative screening for DM by HbA1c measurements from November 2017 to December 2020. Diabetes was defined as screening detected HbA1c ≥ 48 mmol/mol (6.5%) or previously diagnosed diabetes. The association of DM with in-hospital complications, length of stay, and 30-day mortality rate were evaluated using adjusted and unadjusted logistic regression models.
RESULTS: The total prevalence of DM was 15% (95% CI 13%,17%), of which 25% of the DM cases (95% CI 18%,33%) were undiagnosed upon admission for AAA surgery. The OSR to EVAR ratio was 52% versus 48%, with similar distribution among DM patients, and no differences in the prevalence of known and undiagnosed DM in the EVAR versus the OSR group. Total 30-day mortality rate was 0.6% (5/877). Sixty-six organ-related complications occurred in 58 (7%) of the patients. DM was not statistically significantly associated with a higher risk of in-hospital organ-related complications (OR 1.23, 95% CI 0.57,2.39, p = 0.57), procedure-related complications (OR 1.48, 95% CI 0.79,2.63, p = 0.20), 30-day mortality (p = 0.09) or length of stay (HR 1.06, 95% CI 0.88,1.28, p = 0.54). According to post-hoc-analyses, organ-related complications were more frequent in patients with newly diagnosed DM (n = 32) than in non-DM patients (OR 4.92; 95% CI 1.53,14.3, p = 0.005).
CONCLUSIONS: Twenty-five percent of all DM cases were undiagnosed at the time of AAA surgery. Based on post-hoc analyses, undiagnosed DM seems to be associated with an increased risk of organ related complications following AAA surgery. This study suggests universal DM screening in AAA patients to reduce the number of DM patients being undiagnosed and to improve proactive diabetes care in this population. The results from post-hoc analyses should be confirmed in future studies.

BACKGROUND: Ruptured abdominal aortic aneurysms (RAAAs) are among the most dangerous emergencies in vascular surgery, with a high death rate and numerous risk factors influencing perioperative death. Therefore, identifying the critical risk factors for RAAAs is crucial to increasing their survival rate. Our aim was to identify those risk factors from a wide range of parameters.
METHODS: Retrospective analysis of hospitalized RAAA patients treated at this center between May 2004 and January 2023. After comparing the preoperative data of patients who survived and those who died, high-risk characteristics influencing the perioperative care of RAAA patients were identified, and logistic regression analysis was carried out. The mean follow-up time was 45.34 months.
RESULTS: During the study period, a total of 155 patients (average age 67.4 ± 71.93 years, 123 (78.85%) males, 32 (20.51%) females) were enrolled. The patients participating in the group were divided into survival group (n = 123) and death group (n = 27). The main differences included hemodynamic instability (51.9% vs 28.5%; P = 0.019), sudden cardiac arrest (14.8% vs 1.6%; P = 0.010), deterioration of consciousness (40.7% vs 17.1%; P = 0.007), renal impairment (22.2% vs 2.4%; P = 0.001), and chronic kidney disease (18.5% vs3.2%; P = 0.010). There is also a history of cancer (Ca) (18.5% vs 4.1%; P = 0.021). Risk factors for endovascular aneurysm repair (EVAR) include diastolic blood pressure ≤50 mm Hg (36.4% vs 8.0%; P = 0.025), renal function impairment (18.2% vs 0; P = 0.015), and chronic kidney disease (27.3% vs 4.0%; P = 0.028). Risk factors for open surgical repair (OSR) include diastolic blood pressure ≤50 mm Hg (40.0% vs 6.3%; P = 0.014). Finally, the previously mentioned statistically significant factors were analyzed by logistic regression analysis, and it was found that diastolic blood pressure ≤50 mm Hg, cardiac arrest, renal function damage, and Ca history were independent risk factors. We followed 123 individuals and 14 were lost to follow-up, with an overall survival rate of 43.8%.
CONCLUSIONS: Hemodynamics, which includes shock, blood pressure, cardiac arrest, deterioration of consciousness, and other conditions, are the primary risk factors for the perioperative death of a ruptured abdominal aortic aneurysm. Simultaneously, diastolic blood pressure ≤50 mm Hg was found to be associated with risk factors for OSR, whereas renal function impairment, chronic renal illness, and diastolic blood pressure ≤50 mm Hg were associated with the risk for EVAR.

BACKGROUND: Fusion imaging systems have proved to reduce radiation exposure mostly in hybrid rooms but reports with mobile C-arms are few. The aim of this study was to analyze the impact of the Endonaut navigation system on radiation exposure in endovascular aneurysm repair (EVAR) performed with mobile C-arms.
METHODS: All patients undergoing EVAR and/or iliac branched devices implantation between January 2016 and August 2022 were included. All procedures were performed with a mobile C-arm (Siemens Avantic or GE Elite until March 2018, Siemens Cios Alpha thereafter). The Endonaut navigation system has been used since January 2021. Two groups were, therefore, compared: before (control group [CGr]) and after the use of Endonaut. Radiation data including Dose Area Product (DAP) values, Air Kerma (AK) and fluoroscopy time (FT) were collected retrospectively.
RESULTS: Overall, 153 patients were included: CGr, n = 121; Endonaut group (EnGr), n = 32. No significant difference was found between the 2 groups regarding demographic data. DAP values were significantly lower in the EnGr (38 Gy cm2 ± 24) vs. the CGr (76 Gy cm2 ± 51) (P < 0.05) despite a significantly higher number of complex procedures such as iliac branched devices (P < 0.05). AK values were not significantly different between the EnGr and the CGr (196 mGy ±114 vs. 209 mGy ±138) as well as FT (33 minutes ±18 vs. 33 minutes ±16). Technical success was 97% (31/32) in the EnGr vs. 96% (116/121) in the CGr (P = 0.79). The volume of contrast media was significantly lower in the EnGr (94 cc ± 41) vs. the CGr (143 cc ± 66) (P < 0.05).
CONCLUSIONS: In this study, the use of the Endonaut angio-navigation system when performing EVAR with mobile C-arms led to a radiation dose reduction without compromising technical success or procedural time.

BACKGROUND: Cases of abdominal aortic aneurysm discovered as purpura on the extremities with disseminated intravascular coagulation (DIC) are rare. The number of currently established strategies for the control of DIC with aortic aneurysm is limited.
METHODS: An 85-year-old woman was referred to the hematology department because of purpura on her shoulder and thigh. Enhanced fibrinolytic-type DIC was diagnosed by a blood test. Enhanced computed tomography (CT) revealed 60-mm abdominal aortic and 42-mm right common iliac aneurysms. We performed endovascular aneurysm repair (EVAR) and coiling of the right internal iliac artery with postoperative administration of Nafamostat mesylate. The patient promptly recovered from DIC, and the purpura gradually disappeared.
CONCLUSIONS: We safely performed EVAR with postoperative administration of Nafamostat mesylate for an abdominal aortic aneurysms that presented as symptomatic DIC.

BACKGROUND: Endovascular techniques are advancing with the change of treatment paradigm for abdominal aortic aneurysms. Fenestrated EVAR (fEVAR) and branched EVAR (bEVAR) are used for complex aortic aneurysm repair. Both fEVAR and bEVAR have their own advantages and disadvantages. Semi-branches are a new feature that attempt to combine the advantages of both fEVAR and bEVAR.
METHODS: We describe the use of a 4-vessel semi-branched EVAR in a failed EVAR case with a type 1a endoleak.
CONCLUSIONS: The novel feature of semi-branches in custom-made EVAR devices in endovascular aortic treatment following failed EVAR appear to be a feasible option.

Surveillance programs in abdominal aortic aneurysms (AAA) are mainly based on imaging and leave room for improvement to timely identify patients at risk for AAA growth. Many biomarkers are dysregulated in patients with AAA, which fuels interest in biomarkers as indicators of disease progression. We examined associations of 92 cardiovascular disease (CVD)-related circulating biomarkers with AAA and sac volume.
In a cross-sectional analysis, we separately investigated (1) 110 watchful waiting (WW) patients (undergoing periodic surveillance imaging without planned intervention) and (2) 203 patients after endovascular aneurysm repair (EVAR). The Cardiovascular Panel III (Olink Proteomics AB, Sweden) was used to measure 92 CVD-related circulating biomarkers. We used cluster analyses to investigate protein-based subphenotypes, and linear regression to examine associations of biomarkers with AAA and sac volume on CT scans.
Cluster analyses revealed two biomarker-based subgroups in both WW and EVAR patients, with higher levels of 76 and 74 proteins, respectively, in one subgroup versus the other. In WW patients, uPA showed a borderline significant association with AAA volume. Adjusting for clinical characteristics, there was a difference of -0.092 (-0.148, -0.036) loge mL in AAA volume per SD uPA. In EVAR patients, after multivariable adjustment, four biomarkers remained significantly associated with sac volume. The mean effects on sac volume per SD difference were: LDLR: -0.128 (-0.212, -0.044), TFPI: 0.139 (0.049, 0.229), TIMP4: 0.110 (0.023, 0.197), IGFBP-2: 0.103 (0.012, 0.194).
LDLR, TFPI, TIMP4, and IGFBP-2 were independently associated with sac volume after EVAR. Subgroups of patients with high levels of the majority of CVD-related biomarkers emphasize the intertwined relationship between AAA and CVD.ClinicalTrials.gov Identifier: NCT03703947.

The LEOPARD (Looking at EVAR Outcomes by Primary Analysis of Randomized Data) trial is a randomized controlled trial comparing the outcomes of endovascular aneurysm repair (EVAR) using commercially available devices in a real-world population.
A prospective, randomized, multi-center trial was performed to compare the anatomically fixated (AF) AFX/AFX2 endograft system (Endologix) with endografts with proximal fixation (PF) (Cook Medical Zenith Flex; Gore Excluder; and Medtronic Endurant II) in patients with infrarenal abdominal aortic aneurysms. The primary endpoint was freedom from aneurysm-related complications (ARCs), a composite endpoint consisting of perioperative death (≤30 days), aneurysm rupture, conversion to open surgical repair, postoperative endoleaks, endograft migration (≥10 mm), aneurysm enlargement (≥5 mm), endograft limb occlusion, and device- or aneurysm-related reintervention.
The study population was 455 patients enrolled at 56 United States centers: 235 patients were treated with AF devices and 220 with PF devices. The primary endpoint supported noninferiority of the AF cohort at 1 year. The 5-year freedom from ARC Kaplan-Meier estimates were 63.8% for AF patients and 55.5% for PF patients (P = .10). Kaplan-Meier estimates for freedom from aneurysm-related mortality were 98.7% and 97.0% in the AF group and 99.5% and 98.5% in the PF group at 1 and 5 years. There was no difference in aneurysm-related mortality, all-cause mortality, rupture, secondary interventions, and type I and type III endoleak between the two cohorts. The type III endoleak rate at 5 years for the AFX cohort was 1.5% and 0.0% for the comparator cohort (P = .11). There was a lower type II endoleak rate in the AF group at 5 years (78.8% vs 68.4%; P = .037). There were zero open surgical conversions (0.0%) in the AF group and four (2.0%) in the PF group.
The 5-year results from the LEOPARD study demonstrated that there was no clinically significant difference in overall aneurysm-related outcomes between patients randomized to the AFX endograft system or commercially available endografts with proximal fixation.

Introduction: This systematic review with network meta-analysis aimed at comparing the medium-term results of open surgery (OS), fenestrated endovascular repair (FEVAR), and chimney endovascular repair (ChEVAR) in patients with juxta/pararenal abdominal aortic aneurysms (JAAAs/PAAAs). Materials and methods: MEDLINE, SCOPUS, and Web of Science were searched from inception date to 1st July 2022. Any studies comparing the results of two or three treatment strategies (ChEVAR, FEVAR, or OS) on medium-term outcomes in patients with JAAAs/PAAAs were included. Primary outcomes were all-cause mortality, aortic-related reintervention, and aortic-related mortality, while secondary outcomes were visceral stent/bypass occlusion/occlusion, major adverse cardiovascular events (MACEs), new onset renal replacement therapy (RRT), total endoleaks, and type I/III endoleak. Results: FEVAR (OR = 1.53, 95%CrI 1.03-2.11) was associated with higher medium-term all-cause mortality than OS. Sensitivity analysis including only studies that analysed JAAA showed that FEVAR (OR = 1.65, 95%CrI 1.08-2.33) persisted to be associated with higher medium-term mortality than OS. Both FEVAR (OR = 8.32, 95%CrI 3.80-27.16) and ChEVAR (OR = 5.95, 95%CrI 2.23-20.18) were associated with a higher aortic-related reintervention rate than OS. No difference between different treatment options was found in terms of aortic-related mortality. FEVAR (OR = 13.13, 95%CrI 2.70-105.2) and ChEVAR (OR = 16.82, 95%CrI 2.79-176.7) were associated with a higher rate of medium-term visceral branch occlusion/stenosis compared to OS; however, there was no difference found between FEVAR and ChEVAR. Conclusions: An advantage of OS compared to FEVAR and ChEVAR after mid-term follow-up aortic-related intervention and vessel branch/bypass stenosis/occlusion was found. This suggests that younger, low-surgical-risk patients might benefit from open surgery of JAAA/PAAA as a first approach.

UNASSIGNED: Endovascular treatment of abdominal aortic aneurysm (AAA) has been in use for several decades and has become the main treatment for this disease. Iliac branch occlusion (IBO) is a common complication after endovascular treatment. The diagnosis and guidance of contrast-enhanced ultrasound (CEUS) combined with computed tomography angiography (CTA) in the treatment of recurrent IBO after endovascular aneurysm repair (EVAR) are rarely reported. In this case, CEUS gave important hints on the cause of IBO.
UNASSIGNED: We present a 67-year-old male patient who was diagnosed with AAA in 2020 and underwent endovascular treatment in the same period. There was no family history of AAA. The operation process was successful. The CTA re-examination one month after operation showed that the aneurysm was well isolated without obvious endoleak. However, the patient developed intermittent claudication of both lower limbs after operation, but did not receive relevant diagnosis and treatment. Four months after surgery, the patient\'s claudication symptoms of the left lower limb were significantly worse than before, and CTA review revealed left IBO. The left ankle brachial index (ABI) was too low to detect the value. A femoral artery thrombectomy was performed and a stent was extended distal to the left iliac stent. The claudication symptoms improved after surgery. Unfortunately, only two months later, the patient developed rest pain in the left lower limb. CTA examination showed that the left iliac branch was occluded again. The problem in the proximal end of the left iliac branch was observed by CEUS before re-operation, which was also confirmed by digital subtraction angiography (DSA) after thrombectomy. The blood flow was significantly improved after the angle of the proximal iliac branch was adjusted by stent placement. The patient did not show claudication symptoms again during follow-up. Through CEUS, we identified the pathogenic causes which could not be reflected in CTA and formulated the correct treatment plan.
UNASSIGNED: The risk factors of IBO after EVAR are mostly hidden in the process of the initial operation. CEUS can provide more information about postoperative hemodynamics than CTA. The role of CEUS in postoperative follow-up of endovascular treatment of AAA needs to be further explored.

This review discusses the impact of endovascular aneurysm repair on cardiovascular (CV) hemodynamics and the role of stent-graft material, i.e., polytetrafluoroethylene (PTFE) vs. polyester in post-procedural outcomes. Endovascular aneurysm repair has been widely employed in the last decades for thoracic and abdominal aneurysm repair. However, aortic endografts are stiff and alter the native flow hemodynamics. This failure to simulate the native aorta could lead to added strain on the heart, manifesting as increased left ventricular strain, higher pulse pressure, and congestive heart failure later. This could result in adverse CV outcomes. Also, evidence is mounting to support the implication of stent-graft materials, i.e., PTFE vs. polyester, in adverse post-procedural outcomes. However, there is an absence of level one evidence. Therefore, the only way forward is to plan and perform a randomised controlled trial to demonstrate the alterations in the CV hemodynamics in the short and long run and compare the available stent-graft materials regarding procedural and clinical outcomes. We believe the best solution, for now, would be to reduce the stented length of the aorta. At the same time, in the longer term, encourage continuous improvement in stent-graft materials and design.