The Evolution of Aortic Aneurysm Repair: Past Lessons and Future Directions

The history and evolution of aortic aneurysm repair demonstrates an important paradigm within surgery, namely the importance of surgical pioneers and innovators who have\ud strived to achieve technical excellence and improve patient care. It also highlights the wider evolution of surgery from traditional open operative techniques to the modern minimally invasive procedures. The following chapter discusses the surgical innovators and the techniques they have described that have enabled the repair of both thoracic aortic aneurysms (TAA) and abdominal aortic aneurysms (AAA).\ud Aortic aneurysms represent a significant health risk particularly for the elderly population. AAA is the 14th-leading cause of death for the 60- to 85-year–old age group in the United States (10.8 deaths per 100,000 population). TAA by contrast is less frequent with an incidence of 10.4 per 100,000. Both AAA and TAA are known to increase in prevalence with advancing age and have an increased prevalence in males. The risk of aneurysm rupture increases with increasing aneurysm diameter over 5.5-6.0 cm and is the primary indication for the repair of both TAA and AAA.Therefore surgery to repair both AAA and TAA is either pre-emptive to prevent rupture or emergent to repair a rupture. Repair of TAA and AAA by either open or minimally invasive techniques significantly reduces the risk of rupture and improves patient mortality. The establishment of these techniques has required the development of procedures from embryonic thoughts in the minds of the surgeons of antiquity through to the utilisation of ever increasing modern technologies

CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair

Background Endoleaks represent the most common complication after EVAR. Some types are associated with ongoing risk of aneurysm rupture and necessitate long-term surveillance and secondary interventions. Purpose This document, as with all CIRSE Standards of Practice documents, will recommend a reasonable approach to best practices of managing endoleaks. This will include imaging diagnosis, surveillance, indications for intervention, endovascular treatments and their outcomes. Our purpose is to provide recommendations based on up-to-date evidence, updating the guidelines previously published on this topic in 2013. Methods The writing group was established by the CIRSE Standards of Practice Committee and consisted of clinicians with internationally recognised expertise in endoleak management. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select publications in English and relating to human subjects up to 2023. The final recommendations were formulated through consensus. Results Endoleaks may compromise durability of the aortic repair, and long-term imaging surveillance is necessary for early detection and correct classification to guide potential re-intervention. The majority of endoleaks that require treatment can be managed using endovascular techniques. This Standards of Practice document provides up-to-date recommendations for the safe management of endoleaks

The role of contrast enhanced ultrasonography in post-operative surveillance of endovascular aortic aneurysm stent graft repair

MD (Res)Abdominal aortic aneurysms are common and responsible for many deaths. They are treated increasingly by EndoVascular Aneurysm Repair (EVAR) rather than conventional surgery. Approximately 25% of EVAR patients require re-intervention to prevent aneurysm enlargement which can rupture despite previous repair. All EVAR patients undergo life-long surveillance for complications such as stent-graft migration or endoleak. Computed Tomography (CT) has been the ‘gold-standard’ for surveillance accounting for 65% of EVAR costs, and exposes patients to cumulative radiation and nephrotoxic contrast. Duplex Ultrasound Scanning (DUS) has been proposed as an alternative for surveillance with lesser cost and patient risk. However, clinical studies have reported varying results. The addition of microbubble contrast significantly improves endoleak detection rates, making it comparable with CT. The physical properties that affect endoleak detection with DUS have not been determined. It is also unknown specifically which endoleaks’ detection are improved by Contrast Enhanced Aortic Duplex UltraSound Scanning (CEADUSS). To investigate the physical properties of endoleaks, I constructed an EVAR phantom model with a simulated endoleak of variable velocity (fast/slow), position (near/far) and plane (anterior/lateral/posterior). Preliminary studies investigated the behavior of microbubble contrast in the phantom system, and then laboratory experiments tested subjects over 36 variable endoleaks using DUS and CEADUSS. These laboratory experiments were translated clinically with a pilot study of CEADUSS in 10 patients with endoleaks on CT not detected by DUS, undefined endoleak type or origin, or a sac enlargement with no endoleak present. My experiments reveal an insight into factors influencing ultrasound endoleak detection. With this knowledge, the use of these modalities for surveillance protocols can be increased, reducing current CT burden, radiation and nephrotoxic contrast exposure, and overall EVAR cost. Clinical assessment of an endoleak, specifically noting physical characteristics (plane, position and velocity) will improve detection and surveillance

Contrast-enhanced ultrasound and/or colour duplex ultrasound for surveillance after endovascular abdominal aortic aneurysm repair : a systematic review and economic evaluation

Study registration: This study is registered as PROSPERO CRD42016036475. Funding: The National Institute for Health Research Health Technology Assessment programme.Peer reviewedPublisher PD

Aneurysmal Disease of the Thoracic and Abdominal Aorta

The first successful open surgical repair of an abdominal aortic aneurysm was in 1951 by Dubost and represented a tremendous milestone in the care of this challenging disease. The introduction of endovascular repair in 1991 by Parodi furthered the care of these patients by allowing for lower morbidity and mortality rates and also, enabling surgeons to extend surgical treatment to patients traditionally deemed too high of a surgical risk. This new book on Aortic Disease covers many interesting and vital topics necessary for both the practicing surgeon as well as a student of vascular disease. The book starts with background information on the evolution of aortic management from traditional open surgical repair to modern endovascular therapies. There is also a chapter covering the data supporting current treatment modalities and how these data have supported modern management. Also, the use of endovascular means for care of the challenging situation of ruptured aneurysms is discussed. In addition to management of abdominal aneurysm, there is a chapter on treatment of aneurysms of the ascending aorta. Along with surgical treatment, one must also understand the molecular basis for how blood vessels remodel and thus, the role of cathepsins in aortic disease is elucidated. Lastly, chapters discussing the perioperative management of radiation exposure and ultrasound-guided nerve blocks as well as the need for high-quality postoperative nutrition will lend well to a full understanding of how to management patients from presentation to hospital discharge. We hope you enjoy this book, its variety of topics, and gain a fuller knowledge of Aneurysmal Disease of the Thoracic and Abdominal Aorta

Which spring is the best? Comparison of methods for virtual stenting.

This paper presents a methodology for modeling the deployment of implantable devices used in minimally invasive vascular interventions. Motivated by the clinical need to perform preinterventional rehearsals of a stent deployment, we have developed methods enabling virtual device placement inside arteries, under the constraint of real-time application. This requirement of rapid execution narrowed down the search for a suitable method to the concept of a dynamic mesh. Inspired by the idea of a mesh of springs, we have found a novel way to apply it to stent modeling. The experiments conducted in this paper investigate properties of the stent models based on three different spring types: lineal, semitorsional, and torsional springs. Furthermore, this paper compares the results of various deployment scenarios for two different classes of devices: a stent graft and a flow diverter. The presented results can be of a high-potential clinical value, enabling the predictive evaluation of the outcome of a stent deployment treatment